THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


Miliary  Choroido-retinitis. 

(See  Paoe  344.) 


PREVALENT  DISEASES 
OF   THE   EYE 


A  REFERENCE  HANDBOOK,  ESPECIALLY 
ADAPTED  TO  THE  NEEDS  OF  THE  GENERAL 
PRACTITIONER  AND  THE  MEDICAL  STUDENT 


BY 

SAMUEL   THEOBALD,   M.D. 

Clinical  Professor  of  Ophthalmology  and  Otology  in  the  Johns  Hopkins  University 

Ophthalmic  and  Aural  Surgeon  to  the  Johns  Hopkins  Hospital,  and  to  the 

Baltimore  Eve,  Ear,  and  Throat  Chat  ity  Hospital ;  Consulting  Ophthalmic 

and    Aural   Surgeon    to    the    Home    for    Inctirahles,   and    to    the 

South  Baltimore  Eye,  Ear,  and  Throat  Charity  Hospital. 


WITH   219  ILLUSTRATIONS 
AND    10    COLORED    PLATES 


PHILADELPHIA  AND  LONDON 

W.   B.  SAUNDERS    COMPANY 
1907 


3  //S'S    onol     ■B'S2Ce 


CopjTight,  IQ06,  by  W.  B.  Saunders  Company 


Reprinted  April,  1907 


PRESS    OF 

W.   B.  SAUNDERS    COMPANY 

PHILADELPHIA 


;   i  -  ^ 


PREFACE. 


Although  most  treatises  upon  diseases  of  the  eye 
have  been  written  ostensibly  for  the  general  practitioner 
and  the  medical  student,  they  have  been,  with  few  ex- 
ceptions, adapted  in  reality  not  to  their  needs,  but  to 
the  requirements  of  the  specialist  in  this  department  of 
medicine.  A  treatise  upon  the  eye  really  intended  to 
meet  the  needs  of  the  general  practitioner,  it  has  seemed 
to  the  author,  should  take  into  account  the  fact  that  the 
great  majority  of  physicians  are  not  skilled  in  the  use  of 
the  ophthalmoscope,  and  are  not  likely  ever  to  be;  that 
they  possess  neither  the  experience  nor  the  necessary 
paraphernalia  to  make  trustworthy  tests  of  refractive 
errors,  of  muscular  anomalies,  or  of  the  visual  fields; 
and  that  they  are  not  qualified  to  perform,  and  have  no 
desire  to  undertake,  the  more  delicate  eye  operations. 
It  should  recognize,  further,  that  because  of  these  Hmita- 
tions  the  general  practitioner  is  hopelessly  handicapped 
as  regards  the  diagnosis,  and  consequently  the  treat- 
ment, of  many  important  eye  affections;  but,  on  the 
other  hand,  that  there  are  other  important  affections 
of  the  eye  which  he  is  competent,  or  should  be  com- 
petent, to  diagnosticate  correctly,  and  to  treat  success- 
fully. 

It  should,  therefore,  devote  especial  attention  to  this 
latter  class  of  maladies,  and,  particularly,  should  help 
him    to   discriminate   between    these    cases    and   those 


11  PREFACE. 

which  are  without  his  province,  so  that,  on  the  one  hand^ 
he  may  not  send  trivial  affections,  which  he  is  himself 
competent  to  treat,  to  the  distant  speciahst,  or,  on  the 
other  hand,  lose  precious  time,  and  thus  permit  sight 
to  become  irreparably  damaged,  through  attempting  to 
cope  with  maladies  which  urgently  demand  the  skill 
of  the  trained  ophthalmologist. 

Again,  such  a  work  should  take  into  account  that  the 
general  practitioner  is  most  in  need  of  definite  infor- 
mation as  to  the  more  frequently  encountered  diseases 
of  the  eye,  and,  while  these  should  be  dwelt  upon,  that 
it  is  a  w^ork  of  supererogation,  so  far  as  he  is  concerned,  to 
give  space  to  the  description  of  rare  affections  which,  in 
all  probability,  he  will  never  encounter.  It  should  also 
make  clear  to  him  the  sharp  line  to  be  drawn  between 
those  diseases  of  the  eye  in  which  delay  in  the  employ- 
ment of  remedial  measures  is  permissible,  or  even  desir- 
able, and  those  in  the  treatment  of  which  time  is  an  all- 
important  factor. 

In  offering  suggestions  as  to  treatment,  it  should  be 
concise,  unambiguous,  and  as  specific  as  practicable, 
not  giving  a  long  list  of  remedies,  and  leaving  the  inex- 
perienced reader  to  choose  from  among  them,  but 
recommending  definitely  w^hat  the  author — if  he  is 
qualified  to  write  such  a  book — should  know,  from  his 
own  observation,  is  best  adapted  to  the  condition  under 
consideration.  The  simpler  operations,  which  the 
general  practitioner  may  perform,  it  should  describe  in 
detail;  the  more  difficult  ones,  which  he  is  not  warranted 
in  undertaking,  need  not  be  so  described,  though  the 
indications  for  them  should  be  clearly  set  forth. 

For  such  a  book — not  a  complete  treatise  upon  dis- 
eases of  the  eye,  but  a  concise  description  of  the  com- 
moner ocular  maladies — designed  solely  to  meet  the 


PREFACE.  Ill 

needs  of  the  physician  engaged  in  general  practice,  the 
author  is  convinced  there  is  a  real  want;  and  this  want, 
with  what  measure  of  success  it  remains  to  be  seen,  he 
has  endeavored  to  supply. 

Having  in  mind  the  well-worn  proverb,  "a  little 
knowledge  is  a  dangerous  thing,"  he  has  not  thought 
it  desirable  to  encourage  the  general  practitioner  to  rely 
upon  the  ophthalmoscope  as  a  means  of  diagnosis.  In- 
deed, he  has  not  even  given  a  description  of  it,  or  ex- 
plained its  use.  Furthermore,  he  has  constantly  as- 
sumed that  the  knowledge  which  it  affords  is  not  at 
the  reader's  command.  For  the  same  reason,  he  has 
not  given  a  detailed  account  of  the  several  methods  of 
measuring  the  refractive  and  muscular  anomalies  of  the 
eyes,  of  charting  the  visual  fields,  etc.  On  the  other 
hand,  especial  pains  have  been  taken  to  describe  fully 
such  aids  to  diagnosis  (the  examination  by  oblique  il- 
lumination, for  example)  as  can  but  prove  helpful,  and 
such  therapeutic  measures,  operative  and  non-operative, 
as  the  general  practitioner  may  employ  with  advantage. 
The  hope  is  indulged  that  the  introductory  chapters 
upon  "Diagnosis"  and  upon  "Treatment"  will  prove 
of  practical  value. 

For  greatly  appreciated  advice  and  many  helpful  sug- 
gestions in  connection  with  the  preparation  and  publi- 
cation of  this  work,  the  author  takes  pleasure  in  ac- 
knowledging his  indebtedness  to  Dr.  Wm.  H.  Welch  and 
to  Dr.  Henry  M.  Hurd.  He  is  also  indebted  to  Dr. 
Albert  H.  Buck,  editor  of  the  "Reference  Handbook 
of  the  Medical  Sciences,"  for  permission  kindly  accorded 
him  to  make  free  use,  in  writing  Chapters  V  and  VH,  of 
the  articles  upon  "Affections  of  the  Conjunctiva"  and 
upon  "Iritis,"  which  it  was  the  author's  privilege  to 
contribute  to  that  standard  work. 


IV  PREFACE. 

To  Dr.  A.  Maitland  Ramsay  he  is  under  obligation 
for  permission  to  use  several  admirable  illustrations 
from  his  "Atlas  of  External  Diseases  of  the  Eye." 

304  West  Monument  Street, 
Baltimore, 


SYNOPSIS  OF  CONTENTS. 


CHAPTER  I. 


General  Observations  upon  the  Diagnosis  of  Diseases  of  the 
Eye.     Description  of  the  Methods  of  Examining  the  Eye 

Available  to  the  General  Practitioner 17-37 

The  difficulties  in  diagnosticating  diseases  of  the  eye  with  which 
the  general  practitioner  has  to  contend,  17.  Some  of  the  errors 
into  which  he  is  apt  to  fall,  17.  His  skill  in  the  use  of  the  oph- 
thalmoscope rarely  such  as  to  make  it  a  trustworthy  means  of  di- 
agnosis, 19.  Other  methods  of  examining  the  eye,  19.  Oblique 
illumination,  19.  Value  of  the  information  which  it  affords,  21. 
Facility  in  its  employment  easily  acquired,  21.  The  assistance 
afforded  by  a  transitory  mydriatic,  21.  Eversion  of  the  eyelids,  22. 
Determination  of  intra-ocular  tension,  23.  The  reactions  of  the 
pupil,  24.  Variations  in  the  size  and  reactions  of  the  pupil  in 
health  and  disease,  25.  Determination  of  visual  acuteness,  27. 
Simple  method  of  measuring  the  visual  field,  29.  The  patient's 
description  of  his  symptoms  often  misleading,  31.  Pertinent 
questions  which  he  should  be  asked,  31.  Significance  of  his  re- 
plies, 31.  Inspection  of  the  eye  by  daylight,  34.  The  condition 
of  the  lids,  lacrimal  apparatus,  conjunctiva,  cornea,  anterior 
chamber,  iris,  the  appearance  and  behavior  of  the  pupil,  the  ten- 
sion of  the  globe,  and  the  movements  of  the  eyes,  to  be  noted,  34. 
Loss  of  sensibility  of  the  cornea — how  determined,  35.  Diag- 
nostic significance  of  the  different  types  of  vascular  injection  of 
the  eye,  and  of  the  character  and  amount  of  the  discharge  pres- 
ent, 35.  Examination  of  the  anterior  structures  of  the  eye  by 
oblique  illumination,  with  and  without  the  application  of  a 
mydriatic,  36. 

CHAPTER  H. 

General  Observations  upon  the  Treatment  of  Diseases  of 

THE  Eye 38-62 

A  correct  diagnosis  having  been  reached  the  selection  of  the  pro- 
per remedy  to  meet  the  condition  usually  not  difficult,  38.  Im- 
portance of  constitutional  remedies  in  the  treatment  of  diseases 
of  the  eye,  38.  The  local  and  constitutional  remedies  especially 
useful  in  the  treatment  of  eye  diseases,  39.  Indications  for,  and 
contraindications  to,  their  use,  and  the  methods  of  employing 


I  a  SYNOPSIS    OF    CONTENTS. 


them,  39,  40.  Importance  of  an  early  diagnosis,  and  the  prompt 
employment  of  therapeutic  measures,  in  many  affections  of  the 
eye,  40.  Transference  of  infectious  material  through  the  care- 
less use  of  eye-droppers,  41.  Cautions  necessar>'  in  the  employ- 
ment of  poisonous  colly ria,  43.  Colly ria  as  commonly  prepared 
by  the  apothecary'  often  contaminated,  43.  Methods  of  apply- 
ing coUyria  and  ointments  to  the  eye,  44.  Mydriatics,  46.  Atro- 
pin,  the  most  valuable  local  remed\'  in  the  treatment  of  diseases 
of  the  eye,  capable  of  doing  much  harm  when  injudiciously  em- 
ployed, 46.  Possibility  of  its  inducing  glaucoma  in  persons 
beyond  middle  life,  47.  Follicular  conjunctivitis  caused  by  its 
long-continued  use,  48.  Idiosyncrasies  met  with  in  individuals 
with  reference  to  atropin  and  other  mydriatics,  48.  Myotics,  48. 
Indications  for  their  employment,  48.  Their  mode  of  action  in 
glaucoma,  48.  Eserin  the  most  valuable,  49.  How  it  should 
be  employed,  49.  Contraindications  to  its  use,  50.  Astringent 
and  antiseptic  agents,  50.  Useful  especially  in  conjunctival 
affections,  50.  Value  of  silver  nitrate,  protargol,  and  argyrol 
in  the  severer  types  of  conjunctivitis,  51.  The  application  of 
carbolic  acid  and  tincture  of  iodin  to  corneal  ulcers,  5  r .  Cocain 
useful  only  as  an  anesthetic,  51.  Harmful  when  otherwise  em- 
ployed, 52.  Causes  desquamation  of  the  corneal  epithelium, 
and  favors  bacterial  invasion,  52.  Dionin  a  valuable  analgesic 
and  lymphagogue,52.  Opium  a  valuable  local  remedy  in  oca- 
lar  inflammations,  53.  Methodof  employing  it,  53.  Ointments, 
their  preparation  and  uses,  53.  Castor-oil  in  burns  of  the  eye 
and  abrasions  of  the  cornea,  54.  Light  not  the  reprehensible 
thing  it  was  formerly  supposed  to  be,  54.  The  application  of 
heavy  bandages  to  the  eyes,  designed  to  exclude  it,  and  con- 
finement in  ver\'  dark  rooms  detrimental  rather  than  helpful,  54. 
Inflamed  and  painful  eyes,  nevertheless,  should  be  protected 
from  undue  exposure  to  light,  54.  Method  ,oj  examining  and 
making  applications  to  the  eyes  of  children,  57.  Constitutional 
remedies  useful  in  the  treatment  of  diseases  of  the  eye,  57.  The 
value,  and  indications  for  the  employment,  of  mercury,  potas- 
sium iodid,  quinin,  iron,  strychnin,  arsenic,  sodium  pyrophos- 
phate, pilocarpin,  etc.,  in  diseases  of  the  eye,  57-61.  Efi&cacyof 
the  antitoxin  treatment  in  diphtheritic  conjunctivitis,  61. 

CHAPTER  III. 
Diseases  of  the  Eyelids  axd  Orbit 63-117 

Diseases  of  the  Eyelids. 

Blepharitis  marginalis,  63.  Commonly  a  chronic  condition,  63. 
In  children,  eczematous  in  character,  and  usually  due  to  malnu- 
trition and  disturbed  digestion;   in  adults,  to  accommodative 


SYNOPSIS    OF    CONTENTS.  I  b 

PAGE. 

Strain,  64.  Treatment,  65  Hordeolum.  67.  Etiology  and  treat- 
ment, 69.  Eczema,  ji.  Constitutional  and  local  causes,  71. 
General  and  local  treatment,  71.  Chalazion,  "jj,.  Etiology,  74. 
Often  multiple,  74.  Chronic  blepharitis  a  predisposing  cause, 
74.  Treatment,  74.  Non-operative  treatment  seldom  of  avail, 
74.  Description  of  operation  found  most  effectual  and  easiest  of 
performance,  75.  Milium,  77.  Hydrocystoma,  78.  Warts,  78. 
Malignant  growths,  78.  Tarsitis,  79.  Commonly  of  syphilitic 
origin,  79.  Entropion,  80.  Spasmodic  entropion,  81.  May 
result  from  spasm  of  the  orbicularis,  commonly  dependent  upon 
photophobia,  or  from  senile  relaxation  of  the  lid-structures,  81. 
Faulty  construction  of  the  tarsal  cartilage  or  of  the  arrangement 
of  the  orbicularis  a  predisposing  cause,  81.  Organic  entropion, 
81.  Produced  by  contraction  of  scar-tissue  in  or  beneath  the 
palpebral  conjunctiva,  81.  Usually  consequent  upon  trachoma, 
8r.  Treatment  of  spasmodic  and  organic  entropion,  81 .  Opera- 
tive procedures  indicated,  82.  Correction  of  entropion  of  the 
lower  lid  by  the  production  of  an  eschar  with  caustic  potash,  82. 
Ectropion,  88.  Like  entropion,  may  be  caused  by  spasm  of  the 
orbicularis,  by  contraction  of  scar  tissue,  or  by  senile  relaxation 
of  the  lid-structures,  88.  Spasmodic  ectropion,  88.  Etiologj',  88. 
Organic  ectropion,  89.  May  result  from  any  lesion  which  leads 
to  destruction  of  the  external  integument  of  the  lid  or  neighbor- 
ing parts,  8g.  Incomplete  ectropion  of  the  lower  lid  a  not  infre- 
quent complication  of  disease  of  the  lacrimal  apparatus,  89. 
Non-operative  and  operative  treatment  of  the  different  varieties 
of  ectropion,  91.  Snellen's  operation  for  ectropion,  92.  Value 
of  Wolfe  and  Thiersch  grafts  in  operations  for  the  correction  of 
ectropion,  97.  Ptosis,  98.  Occurs  as  a  congenital  and  as  an 
acquired  fault,  98.  Acquired  ptosis,  98.  Commonly  due  to 
paralysis  of  the  third  nerve,  98.  Generally  unilateral  and  of 
syphilitic  origin,  98.  Congenital  ptosis,  98.  Usually  bilateral 
and  caused  by  faulty  innervation,  or  imperfect  development  or 
absence,  of  the  levator  muscle,  98.  Treatment,  99.  Only  opera- 
tive treatment  of  avail  in  congenital  ptosis,  99.  In  acquired 
ptosis  operative  measures  indicated  only  after  other  means  have 
proved  ineffectual,  99.  Gruening's  modification  of  Bowman's 
operation  for  ptosis,  102.  Panas'  operation,  104.  Paralysis  of 
the  facial  nerve,  105.  Symptoms  and  consequences,  105.  Eti- 
ologj'.  106.     Treatment,  106. 

Diseases  of  the  Orbit. 

Cellulitis  of  the  orbit,  108.  Acute  and  chronic  forms  of  the  affec- 
tion, 108.  Symptoms,  108.  Etiology,  108.  Fatal  consequences 
from  cerebral  implication,  109.  Treatment,  109.  Periostitis, 
caries,  and  necrosis  of  the  orbital  tcalls,  iii.     Causes  and  conse- 


2  SYNOPSIS    OF    CONTENTS. 

PAGE. 

quences,    iii.  Treatment,  112.     Value  of  hydrochloric  acid, 

113.       Tumors  0/    the    orbit,    113.       Mode    of    origin,    113. 

Varieties,  114.  Consequences,  114.  Diagnosis,  115.  Treat- 
ment, 116. 

CHAPTER  IV. 
Diseases   of   the   Lacrimal   Apparatus -. 118-150 

Diseases  of  the  Lacrimal  Gland. 
Of  infrequent  occurrence,  because  of  the  protected  position  of 
the  gland  and  its  multiple  system  of  ducts,  118.  Dacryoade- 
nitis,  119.  Occurs  as  an  acute  and  as  a  chronic  affection,  118. 
Possible  relationship  to  mumps,  119.  Acute  dacryoadenitis, 
119.  Chronic  dacryoadenitis,  119.  Treatment,  120.  Fistula 
oj  the  lacrimal  gland,  120.  Dacryops,  121.  Dacryoliths,  122. 
Dislocation  0}  the  lacrimal  gland,  122.  Met  with  as  a  sponta- 
neous condition  and  as  a  consequence  of  trauma,  122.  Hyper- 
trophy of  the  lacrimal  gland,  123.     Atrophy  of  the  lacrimal  gland, 

124.  Tumors  of  the  lacrimal  gland,  125.  Are  rare,  and  not  infre- 
quently of  traumatic  origin,  125.  Varieties,  125.  Treatment, 
125- 

Diseases  of  the  Drainage  Apparatus. 
Of  common  occurrence,  125.     Intimate  pathological  relation- 
ship between  the  drainage  apparatus  and  the  nasal  passages, 

125.  Atresia  of  the  lacrimal  piincta,  126.  Occurs  as  a  congeni- 
tal and  as  an  acquired  condition,  126.  Treatment,  127.  Mal- 
position of  the  puncta,  128.  Eversion  of  the  puncta,  12S.  In- 
version of  the  puncta,  128.  Etiology-  and  treatment,  128.  Di- 
vision of  the  canaliculus  the  efficient  remedy,  128.  Description 
of  the  operation,  128.  Atresia  of  the  canaliculi,  130.  Dacryo- 
liths, 131.  Polypi,  131.  Dacryocystitis,  131.  Etiologj',  131. 
Primary  inflammation  of  the  lacrimal  sac,  131.  Blennorrhea  of 
the  lacrimal  sac,  132.  Symptoms,  132.  Mucocele,  132.  Course 
of  the  disease,  132.  Acute  dacryocystitis,  133.  Lacrimal  fis- 
tula an  occasional  consequence,  134.  Dacr}'ocystitis  rarely 
dependent  upon  ocular  disease,  135.  Treatment,  136.  Pre- 
lacrimal  abscess,  137.  Stricture  of  the  nasal  duct,  137.  Its  eti- 
ology', 137.  Symptoms  and  consequences,  138.  Treatment,  140. 
The  efficacy  of  thorough  dilatation  by  means  of  probes  large 
enough  to  restore  the  normal  caliber  of  the  duct,  140.  Author's 
series  of  lacrimal  probes,  141.  Electrolysis,  149.  Removal  of 
the  lacrimal  gland,  149.  Excision  of  the  lacrimal  sac  and  its 
destruction  with  the  actual  cautery,  149.  Dacryocystitis  and 
occlusion  of  the  nasal  duct  in  the  new-born,  150. 


SYNOPSIS    OF    CONTENTS.  3 

CHAPTER  V.  PAGE. 

Diseases   of   the   Co>rjuNCTivA 1 51-201 

Diseases  of  the  conjunctiva  of  common  occurrence,  151.  Im- 
portance of  a  correct  diagnosis  in  dealing  with  them,  151.  Signs 
and  symptoms  of  inflammation  of  the  conjunctiva,  151.  Severe 
remedies,  which  cause  pain  and  increase  photophobia  and  lacri- 
mation,  rarely  indicated,  152.  Hyperemia  of  the  conjunctiva, 
152.  Conjunctivitis,  154.  Catarrhal  conjunctivitis,  154.  Puru- 
lent or  gonorrheal  conjunctivitis,  158.  Ophthalmia  neonato- 
rum, 165.  Croupous  conjunctivitis,  168.  Diphtheritic  con- 
junctivitis, 169.  Follicular  conjunctivitis,  173.  Trachomatous 
conjunctivitis,  1 74.  Serious  consequences  to  which  it  gives  rise, 
174.  Vernal  conjunctivitis,  183.  Bulbar  and  palpebral  types, 
183.  Phlyctenular  conjunctivitis,  186.  Of  constitutional  origin, 
186.  Toxic  conjunctivitis,  ig2.  Argyria  conjunctiva,  yg^.  Sub- 
conjunctival hemorrhage,  193.  Pinguecula,  194.  Pterygium, 
195.  Author's  view  of  its  etiolog)',  196.  Pseudo-pterygium,  197. 
Operative  treatment  of  pterygium,  198. 

CHAPTER  VI. 
Diseases  of  the  Cornea  and  Sclera 202-245 

Diseases  of  the  Cornea. 

Keratitis,  202.  Divisible  into  suppurative  and  non-suppurative 
keratitis,  202.  Suppurative  keratitis,  204.  Etiology,  204. 
Tractable  and  intractable  types,  204.  Phlyctenular  keratitis, 
205.  Abscess  and  ulcer  of  the  cornea,  207.  Pathology,  207. 
Etiology,  210.  Often  of  traumatic  origin,  211.  Treatment, 
local  and  constitutional,  211.  Employment  of  carbolic  acid,  213. 
Use  of  thermo-cautery,  214.  Keratomalacia,  215.  Neuropathic 
keratitis,  216.  Herpes  zoster  ophthalmicus,  218.  Post-malarial 
keratitis,  220.  Dendritic  keratitis,  220.  Herpes  cornea;  jebri- 
lis,  220.  Nonsuppurative  keratitis,  233.  Interstitial  keratitis, 
223.  Always  dependent  upon  inherited  syphilis,  223.  Obstin- 
acy its  chief  characteristic,  225.  Though  ultimate  prognosis 
good,  226.  Treatment,  227.  Pannitic  keratitis,  231.  Can- 
thotomy  in  treatment  of  pannitic  keratitis,  233.  Opacities  of  the 
cornea,  235.  Arcus  senilis,  235.  Nebulae,  Macula,  Leucomata, 
236.  Leucoma  adherens,  236.  Staphyloma  of  the  cornea,  239. 
Etiology,  238.  May  be  partial  or  complete,  238.  Conical 
cornea,  241.     Attended  by  a  high  degree  of  myopia,  241. 

Diseases  of  the  Sclera. 

The  tough  and  non-vascular  sclera  not  often  the  seat  of  disease, 
242.  Scleritis,  242.  Acute,  diffuse  scleritis,  242.  Commonly 
of  rheumatic  origin,  242.  Chronic  scleritis,  243.  Complicated 
by  involvement  of  the  cornea,  243.     Episcleritis,  244. 


^  SYNOPSIS    OF    CONTENTS. 

CHAPTER  VII.  PAGE. 

Diseases  of  the  Iris  and  Ciliary  Body 246-274 

Diseases  of  the  Iris, 

Iritis,  246.  Diagnostic  signs  and  symptoms,  246.  Etiology, 
248.     Consequences  of  neglected  iritis,  250.     Varieties  of  iritis, 

250.  Plastic,  serous,  and  purulent  iritis,  250.     Rheumatic  iritis, 

25 1 .  Gonorrheal  iritis,  251.  "  Trophic  "  nerve  iritis,  252.  Serous 
iritis,  252.  Plastic  iritis,  253.  Syphilitic  iritis,  254.  Iritis 
condylomatosa,  255.  Iritis  gummosa,  255.  Varieties  of  "tro- 
phic" nerve,  or  neuropathic,  iritis,  255.  Sympathetic  iritis 
{sympathetic  ophthalmitis),  256.  Etiology,  256.  Sympathetic 
irritation,  257.  Iritis  due  to  herpes  zoster  ophthalmicus,  259. 
Spongy  iritis,  259.  Chronic  iritis,  260.  Treatment  of  the 
different  varieties  of  iritis,  260. 

Diseases  of  the  Ciliary  Body. 

Cyclitis,  268.  Plastic  cyclitis,  26S.  Purulent  cyclitis,  268. 
Serous  cyclitis,  268.  Treatment  of  the  several  varieties  of 
cyclitis,  269.  Tumors  of  the  ciliary  body,  269.  Often  of  ma- 
lignant type,  269.  An  early  diagnosis  of  the  utmost  importance, 
269.  Can  be  made  only  with  the  aid  of  the  ophthalmoscope, 
269. 

CHAPTER  VIII. 

Glaucoma 275-294 

Importance  of  an  early  diagnosis,  275.  Consequences  of  failure 
to  recognize  glaucoma  in  its  incipiency,  275.  Hardening  of  the 
eyeball  the  essential  feature  of  glaucoma,  275.  Impairment  of 
vision  in  glaucoma,  275.  Primary  glaucoma,  276.  Secondary 
glaucoma,  276.  Primary  glaucoma  extremely  rare  in  persons 
under  thirty  years  of  age,  276.  Secondary  glaucoma  may  mani- 
fest itself  at  any  period  of  life,  276.  Varieties  of  primary  glau- 
coma, 276.  Buphthalmos,  276.  Symptoms,  subjective  and 
objective,  of  inflammatory  glaucoma,  277.  Prodromal  symp- 
toms, 279.  Factors  which  have  to  do  with  precipitating  the 
acute  exacerbations  of  glaucoma,  280.  Consequences  of  un- 
checked inflammatory  glaucoma,  281.  Inexcusable  mistakes 
made  in  diagnosticating  glaucoma,  281.  Glaucoma  to  be  sus- 
spected  whenever  a  painful  inflammation  of  the  eye,  attended 
by  impairment  of  sight,  is  encountered  in  an  individual  who  has 
reached  middle  Ufa,  281.  Etiology  of  inflammatory  glaucoma, 
281.  Accommodative  strain  an  important  factor  in  the  causa- 
tion of  glaucoma,  285.  Influence  of  mydriatics  in  precipitating 
an  attack  of  glaucoma,  when  a  predisposition  to  the  disease 
exists,  285.  Contraction  of  the  visual  held  in  glaucoma,  286. 
Treatment  of  inflammatory  glaucoma,  287.    Iridectomy  thesov- 


SYNOPSIS    OF    CONTENTS.  ' 

PAGE. 

ereign  remedy,  287.  The  value  of  myotics  in  glaucoma,  288. 
Nature  of  their  action,  288.  Manner  of  their  employment,  288. 
Dionin useful  in  conjunction  with  eserin,  289.  Other  non-opera- 
tive measures  useful  in  glaucoma,  289.  Importance  of  correcting 
refractive  and  muscular  anomalies  in  the  incipient  stage  of  glau- 
coma, 290.  Simple  glaucoma,  291.  Symptoms  and  clinical 
history,  291.  The  ophthalmoscope  and  perimeter  necessary  to 
its  diagnosis,  291.  Treatment,  292.  Iridectomy  not  the  effec- 
tive remedy  it  is  in  the  inflammatory  type  of  the  disease,  292. 
Sympathectomy  of  doubtful  value,  293.  The  systematic  use 
of  eserin,  293.  The  constitutional  measures  indicated,  293. 
Secondary  glaucoma,  293.  Etiology,  293.  Symptoms  and 
consequences,  294.     Treatment,  294. 


CHAPTER  IX. 
Diseases  of  the  Crystalline  Lens  and  Vitreous  Humor 295-337 

Diseases  of  the  Crystalline  Lens. 

Anatomy  and  histology  of  the  lens,  295.  Growth  of  the  lens,  295. 
Changes  which  it  undergoes  with  advancing  age,  296.  Signifi- 
cance of  these  changes,  297.  With  reference  to  presbyopia,  297. 
With  reference  to  the  development  of  cataract,  297.  Nutrition  of 
the  lens,  297.  Cataract,  297.  Origin  of  the  name,  297.  Mis- 
taken views  of  the  Greeks  and  Romans  as  to  the  real  nature  of 
cataract,  297.  Though  encountered  most  frequently  in  old  age, 
occurs  at  all  periods  of  life,  and  may  be  of  congenital  origin,  298. 
Different  classifications  of  cataract,  298.  Senile  or  hard  cata- 
ract, 298.  Juvenile  or  soft  cataract,  298.  General  cataract, 
298.  Partial  cataracts,  298.  Varieties  of  partial  cataract,  298. 
Zonular  cataract,  299.  Anterior  polar  cataract,  299.  Posterior 
polar  cataract,  299.  Congenital  cataract,  299.  Idiopathic  cata- 
ract, 299.  Complicated  cataract,  299.  Traumatic  cataract,  299. 
Immature,  mature,  and  hypermature  cataract,  299.  Secondary 
or  capsular  cataract,  299.  General  cataract,  299.  Features  com- 
mon to  the  several  varieties  of  general  cataract,  299.  Progressive 
impairment  of  vision  in  general  cataract,  299.  Characteristics 
of  soft  and  of  hard  cataract,  301.  "  Second  sight"  a  premonitory 
symptom  of  senile  cataract,  302.  Etiology  of  general  cataract, 
302.  The  development  of  cataract  a  degenerative,  not  an  inflam- 
matory, process,  302.  Faulty  nutrition  of  the  lens  the  immediate 
cause  of  cataract,  302.  This  may  be  the  result  of  a  constitu- 
tional disorder,  of  senile  decay,  or  of  pathological  changes  in  the 
eye  itself,  302.  Life-long  accommodative  strain  a  not  unimpor- 
tant factor  in  the  causation  of  senile  cataract,  303.  Etiology  of 
traumatic  cataract,  303.  Diagnosis  of  cataract,  304.  Assistance 
afforded  by  oblique  illumination  and  the  instillation  of  a  mydri- 


SYNOPSIS    OF    CONTENTS. 

PAGE. 

atic,  304.  Determination  of  the  maturity  of  cataract,  307. 
Treatment  of  cataract,  310.  Improvement  in  vision  in  incipient 
cataract  from  the  use  of  a  mydriatic,  310.  Discission,  the  pro- 
cedure applicable  to  soft  or  juvenile  cataract,  314.  Extraction, 
applicable  to  hard  or  senile  cataract,  315.  Simple  and  com- 
bined extraction,  315.  The  success  which  attends  extraction  of 
cataract  at  the  present  day,  316.  Conditions  which  militate 
against  the  success  of  the  operation,  316.  Linear  extraction, 
319.  Suction  extraction,  319.  Partial  Cataract,  320.  Ante- 
rior polar  cataract,  320.  Pyramidal  cataract,  321.  Posterior 
polar  cataract,  322.  Zonular  cataract,  324.  Treatment  of  the 
several  varieties  of  partial  cataract,  325.  Capsular  cataract, 
326.  Etiolog)-  and  treatment  of  capsular  cataract,  326,  327. 
Dislocation  0}  the  crystalline  lens,  327.  May  be  complete  or 
incomplete,  327.  ]May  be  forward,  into  the  anterior  chamber, 
or  backward,  into  the  vitreous  chamber,  327.  Effect  upon  vis- 
ion, 329.     Treatment,  331. 

Diseases  of  the  Vitreous  Humor. 

Pathological  changes  in  the  vitreous  humor  usually  due  to  trau- 
matism or  to  pre-existent  disease  of  the  uveal  coat  or  retina,  333. 
Purulent  panophthalmitis,  333.  Treatment,  334.  Fluidity 
of  the  vitreous  humor,  334.  Opacities  of  the  vitreous  humor,  334. 
Muscm  volitantes,  335.  Hemorrhage  into  the  vitreous  humor, 
336.     Etiology,  336.     Treatment,  337. 


CHAPTER  X. 

Diseases  of  the  Choroid  Coat,  Retixa,  and  Optic  Nerve 338-387 

General  description  of  the  symptoms  indicative  of  disease  of  the 
choroid,  retina,  and  optic  nerve,  which,  when  taken  into  ac- 
count, enable  the  general  practitioner,  even  without  the  aid  of 
the  ophthalmoscope,  to  reach  an  approximately  accurate  diag- 
nosis, 338. 

Diseases  of  the  Choroid  Coat. 
Choroiditis,  340.  May  be  plastic,  purulent,  or  serous  in  type, 
340.  Purulent  choroiditis,  synonymous  \\'ith  purulent  panoph- 
thalmitis, described  in  Chapter  IX,  340.  Serous  choroiditis,  syn- 
onymous with  uveitis,  considered  in  Chapter  VH,  340.  Plastic 
choroiditis,  340.  Frequently  dependent  upon  syphilis,  340. 
Syphilitic  choroiditis,  340.  Commonly  involves  the  retina,  340. 
Runs  a  tedious  course,  341.  Both  eyes  usually  affected,  341. 
If  neglected  may  lead  to  loss  of  sight  and  to  the  development  of 
cataract,  342.  Choroiditis  of  high  myopia,  342.  Traumatic  cho- 
roiditis, 342.  Miliary  choroido-retinitis,  343.  A  not  uncommon 
consequence  of  accommodative  strain,  343.     Probably  a  factor, 


SYNOPSIS    OF    CONTENTS. 


of  no  mean  importance,  in  the  causation  of  glaucoma  and  of 
senile  cataract,  344.  Treatment  of  the  several  varieties  of  cho- 
roiditis, 345.     Tumors  of  the  choroid,  348. 

Diseases  of  the  Retina. 

Retinitis,  348.  Divisible  into  primary  and  secondary  retinitis, 
348.  Also  into  serous  and  parenchymatous  retinitis,  348.  Ret- 
initis unattended  by  photophobia  or  pain,  348.  Impairment 
of  vision  the  chief  subjective  symptom,  348.  Causes  of  primar}' 
and  of  secondary  retinitis,  349.  Retinitis  albuminurica,  349. 
Occurs  in  all  forms  of  disease  of  the  kidney  accompanied  by  al- 
buminuria, and  not  infrequently  as  an  early  symptom,  349.  Also 
in  the  albuminuria  of  pregnancy  and  of  scarlatina,  349.  Nearly 
always  bilateral,  349.  Uremic  amblyopia,  351.  Treatment 
to  be  directed  to  the  nephritis  and  to  the  general  condition  of  the 
patient,  351.  Diabetic  retinitis,  351.  Is  always  bilateral,  351. 
Not  infrequently  accompanied  by  cataract,  and  occasionally  by 
iritis  or  glaucoma,  351.  Prognosis  unfavorable,  352.  Treat- 
ment, 352.  Leucocythemic  retinitis,  352.  Retinitis  of  perni- 
cious anemia,  352.  Syphilitic  retinitis,  353.  Energetic  anti- 
syphilitic  treatment  demanded,  353.  Retinitis  jrom  exposure 
of  the  eyes  to  intense  light,  353.  Usually  most  marked  in  the 
macular  region,  353.  Treatment,  354.  Retinitis  pigmentosa, 
354.  Begins  in  early  childhood,  354.  May  be  congenital,  354. 
Often  associated  with  congenital  anomalies  of  the  eye  or  of  other 
organs,  354.  Met  with  in  the  offspring  of  consanguineous  mar- 
riages, 354.  Night-bHndness  an  early  symptom,  355.  Grad- 
ual contraction  of  visual  field,  with  ultimate  loss  of  central 
vision,  355.  Treatment  of  Uttle  avail,  356.  Embolism  of  the 
central  artery  of  the  retina,  357.  Characterized  by  sudden  loss 
of  sight  of  the  affected  eye,  357.  Striking  ophthalmoscopic 
picture,  exhibiting  the  "cherry-red  spot  at  the  macula,"  357. 
Treatment,  358.  Thrombosis  of  the  central  artery  of  the  retina, 
359.  Probably  the  cause  of  the  sudden  loss  of  sight  occasionally 
observed  in  acute  anemia,  359.  Symptoms  and  ophthalmo- 
scopic picture  similar  to  those  observed  in  embolism,  359. 
Thrombosis  0}  the  central  retinal  vein,  359.  Usually  met  with  in 
elderly  persons  with  organic  heart  disease  or  angiosclerosis,  359. 
May  be  caused  by  the  extension  of  facial  erysipelas  to  the  orbit, 

359.  The  ophthalmoscope  shows  enormous  distention  and 
great  tortuosity  of  the  retinal  veins,  with  numerous  hemorrhages 
scattered  over  the  entire  fundus,  360.     Treatment  of  little  avail, 

360.  Detachment  of  the  retina,  360.  Its  etiology,  361.  Far- 
fetched theories  advanced  to  explain  its  occurrence  unsatisfying, 

361.  Oftenest  met  with  in  high  myopia,  361.  May  result  from 
trauma,  361.     Occurs  in  conjunction  with  intraocular  growths, 

362.  Symptoms,    362.     Annoying    disturbance    of    vision    to 


SYNOPSIS    OF    CONTENTS. 


which  it  gives  rise,  363.  Prognosis  most  unfavorable,  363. 
Operative  and  non-operative  treatment,  364.  Glioma  0/  the 
retina,  364.  One  of  the  most  mahgnant  of  pathological  new- 
growths,  364.  Possibility  of  diagnosticating  it  by  daylight  in- 
spection, with  the  assistance  of  a  mydriatic,  365.  Symptoms 
and  course  of  the  disease,  365.  Enucleation  of  the  eye  at  the 
earliest  moment  possible  indicated,  366.  But  recurrence  of  the 
growth,  especially  in  the  brain,  to  be  feared,  367.  A  disease 
of  childhood,  365. 

Diseases  of  the  Optic  Nerve, 

Optic  neuritis,  367.  Divisible  into  retrobulbar  neuritis  and  intra- 
ocular neuritis,  367.  The  latter  again  divisible  into  papillitis, 
or  choked  disc,  and  descending  optic  neuritis,  367.  Etiolog}'  of 
descending  optic  neuritis  and  of  choked  disc,  368.  Choked 
disc  {papillitis),  370.  Vision  at  first  may  be  but  slightly  im- 
paired, though  pronounced  fundus  changes  are  present,  371. 
Usually  dependent  upon  intracranial  tumor,  371.  Present  in 
from  eighty  to  ninety  per  cent,  of  intracranial  new-growths,  371. 
Descending  optic  neuritis,  372.  Fundus  changes  less  marked 
than  in  choked  disc,  372.  Oftenest  due  to  basilar  meningitis 
attended  by  inflammation  of  the  contiguous  brain  substance, 
372.  The  prognosis  in  both  choked  disc  and  descending  optic 
neuritis  largely  dependent  upon  the  nature  of  the  lesion  which 
has  led  to  their  development,  372.  Treatment,  373.  Retro- 
bulbar optic  neuritis  {orbital  neuritis),  374.  Occurs  under  two 
forms — Acute  retrobulbar  neuritis  and  chronic  retrobulbar  neu- 
ritis, or  toxic  amblyopia,  374,  375.  In  each  the  orbital  portion  of 
the  nerve  is  first  involved,  and  especially  the  papillo-macular 
fibers,  375.  Acute  retrobulbar  neuritis,  374.  Etiolog}^,  374 
Symptoms  and  course  of  the  disease,  374,  375.  Treatment,  375 
Chronic  retrobulbar  neuritis  {toxic  amblyopia),  375.  Etiolog}' 
375.     Symptoms,    375.     Ophthalmoscopic    changes    observed 

377.  Prognosis  and  treatment,  377.  Quinin  blindness,  ;^-j-j 
Atrophy   of   the  optic  nerve,   378.     Primary   {simple)  atrophy 

378.  Nearly  always  bilateral,  379.  Etiolog}-,  379.  Early 
symptoms,  379.  Ophthalmoscopic  signs,  379.  Treatment 
usually  of  little  avail,  381.  Consecutive  atrophy  of  the  optic 
nerve  {inflammatory  atrophy),  381.  Causes,  381.  Sub- 
jective and  objective  symptoms,  381.  Diagnosis  to  be  estab- 
lished only  by  the  ophthalmoscope,  381.  Usually  distinguish- 
able from  simple  atrophy,  381.  Prognosis  not  so  unfavorable 
as  in  simple  atrophy,  382.  Treatment,  382.  Hemianopsia, 
383.  Varieties,  383.  Binasal  and  horizontal  hemianopsia, 
uncommon,  384.  Homonyjnous  lateral  hemianopsia  and  bi- 
temporal hemianopsia  more  frequently  encountered,  385.  Ex- 
planation of  the  occurrence  of  the  different  varieties  of  hemian- 


PAGE. 


SYNOPSIS    OF    CONTENTS. 


opsia,  385.  Homonymous  lateral  hemiatiopsia,  385.  Causes, 
385.  Early  and  later  symptoms,  385.  Central  vision  seldom 
lost,  385.  Transient  hemianopsia,  386.  Bitemporal  hemi- 
anopsia, 386.  Treatment,  except  in  cases  of  syphilitic  origin, 
usually  without  avail,  387. 

CHAPTER  XI. 
Anomalies  of  Refraction  and  Accommodation 388-437 

Anomalies  of  Refraction. 

Prevalent  misconceptions  in  regard  to  the  measurement  and 
correction  of  the  refractive  and  muscular  anomalies  of  the  eyes, 

388.  No  branch  of  ophthalmic  practice  more  imperatively 
demands  especial  skill  and  training,  388.  The  harm  which 
comes  from  the  hap-hazard  methods  of  the  tyro  who,  after  a  few 
weeks'  instruction  in  an  "optical  college,"  announces  himself 
as  an  "ophthalmic  optician,"  388.  Importance  of  the  role 
errors  of  refraction  play  in  the  causation  of  ocular  maladies, 

389.  Also  in  the  production  of  maladies  other  than  those  of  the 
eye,  though,  as  to  these,  there  has  been  much  exagger- 
ation, 389.  Eye-strain  a  common  cause  of  headache,  neuras- 
thenia, vertigo,  disturbance  of  mental  concentration,  etc.,  390. 
Observations  upon  some  of  the  prevalent  misconceptions  regard- 
ing refractive  errors,  and  concerning  the  indication  for  "glasses" 
and  their  influence  upon  sight,  391.  Errors  of  refraction  rarely 
"outgrown,"  and  not  to  be  gotten  rid  of  by  "rest  of  the  eyes," 
massage,  the  application  of  drugs,  etc.,  391.  Glasses  not  to  be 
regarded  as  a  dernier  ressort,  391.  Glasses  do  not  "weaken  the 
sight,"  as  is  popularly  supposed,  391.  No  foundation  for  the 
belief  that  if  glasses  are  worn  in  childhood  a  time  may  come 
when  it  will  be  impossible  to  obtain  them  of  the  required  strength, 

391.  Glasses  given  not  merely  to  sharpen  vision;  but  to  relieve 
eye-strain,  391.  Often  demanded  when  there  is  normal  acute- 
ness  of  sight,  392.  E.xert  a  marked  influence  in  checking  the 
progress  of  myopia,  392.  But  it  is  not  to  be  expected  that  they 
will  "cure"  the  refractive  fault  for  which  they  are  prescribed, 
and  only  exceptionally  does  it  happen  that  they  can  be  put  aside, 

392.  Not  all  eyes  needing  glasses  make  a  direct  appeal  for  their 
aid,  392.  Not  infrequently,  when  the  remote  consequences  of  eye- 
strain are  pronounced,  there  may  be  no  complaint  of  the  eyes 
themselves,  392.  Emmetropia,  393.  Ametropia,  394.  A  gen- 
eral term  denoting  a  departure  from  the  normal  in  the  optical 
construction  of  the  eye,  394.  Hypermetropia  {far-sightednes.i) , 
395.  The  most  prevalent  form  of  ametropia,  and  nearly  always 
of  congenital  origin,  395.  Owing  to  an  abnormal  flatness  of  the 
eyeball,  or  a  lack  of  refractive  power  in  its  lens  system,  the  hyper- 


10  SYNOPSIS    OF    CONTENTS. 


metropic  eye  is  incapable  of  focusing  uj)(jn  the  retina  parallel 
rays  of  light,  without  an  effort  of  accommodation,  395.  Facul- 
tative and  non-facultative  hypermetropia,  395.  Axial  hyper- 
metropia,  397.  Curvature  hypermetropia,  397.  The  ill  conse- 
quences of  hypermetropia,  398.  The  most  important  factor  in 
the  causation  of  convergent  squint,  398.  Asthenopia,  headache, 
blepharitis  marginalis,  etc.,  common  consequences  of  the  eye 
strain  to  which  it  gives  rise,  398.  The  ill  effects  of  the  higher 
grades  of  hypermetropia  manifest  themselves  in  early  childhood, 

398.  The  lower  grades  may  cause  no  inconvenience  until 
the  presbyopic  age  is  approached,  399.  The  whole  treat- 
ment of  hypermetropia  comprised  in  the  careful  adjust- 
ment of  glasses,  399.  Whether  these  must  be  worn  con- 
stantly, or  only  in  near  vision,  will  depend  upon  the  degree 
of  the  refractive  fault,  the  power  of  accommodation,  and 
the  relative   strength  of    external   and  internal  recti  muscles, 

399.  With  properly  adjusted  glasses  the  hyperir.etropic  eye 
is  relieved  of  all  strain,  and  is  capable  of  doing  the  work  which 
the  normal  eye  does  without  assistance,  400.  Influence  which 
the  correction  of  hypermetropia  by  glasses  exerts  upon  the  de- 
velopment of  convergent  squint,  402.  A  squint,  as  yet  not  fully 
established,  can  always  be  corrected  by  properly  adjusted 
glasses,  402.  A  fully  established  squint,  only  exceptionally,  402. 
More  often  than  not  hypermetropia  is  complicated  by  the  co- 
existence of  astigmatism,  403.  For  this  reason,  and  because  the 
judicious  correction  of  hypermetropia  presupposes  a  clear  com- 
prehension of  the  muscular  anomalies  of  the  eye,  it  is  manifest 
that  the  treatment  of  this  very  prevalent  refractive  fault  should 
be  undertaken  only  by  the  physician  who  has  had  especial  train- 
ing and  experience,  403.  Myopia  {short-sightedness),  403. 
Much  less  common  than  hypermetropia,  and  nearly  always  an 
acquired  fault,  403.  Owing  either  to  the  antero-posterior  axis 
of  the  eye  being  too  long,  or  to  an  excess  of  power  in  its  lens 
system,  rays  of  light  are  brought  to  a  focus  before  reaching  the 
retina,  403.  Axial  myopia,  404.  Curvature  myopia,  404. 
Axial  myopia,  the  more  common  type,  usually  due  to  the  de- 
velopment of  a  posterior  staphyloma,  404.  Conical  cornea  a 
striking  example  of  curv'ature  myopia,  405.  Etiology  of  axial 
myopia,  405.  Disturbed  relation  of  accommodation  and  con- 
vergence in  myopia,  407.  A  cause  of  asthenopia,  and  may  lead 
to  the  development  of  divergent  squint,  408.  Myopia  oc- 
casionally a  result  of  acute  systemic  disease,  408.  Origin  of  the 
name  "myopia,"  409.  The  ophthalmoscope  affords  the 
readiest  means  of  diagnosticating  myopia,  409.  Treatment,  409. 
Whether -the  defect  shall  increase  to  the  danger-point,  or  shall 
be  arrested  before  the  deeper  structures  of  the  eye  have  suffered 
irreparable  damage,  hinges  upon  the  skill  exercised  in  its  cor- 


SYNOPSIS    OF    CONTENTS.  II 

PAGE. 

rection  by  glasses,  410.  Importance  of  correcting  associated  astig- 
matism, and  of  taking  into  account  the  muscle-balance  in  both 
far  and  near  vision,  410.  The  widespread  belief  that  in  myopia 
glasses  are  called  for  only  in  distant  vision,  seldom  well  founded, 
411.  In  distant  vision  they  are  a  convenience;  in  near  vision, 
a  therapeutic  agent  of  great  value,  411.  Operative  procedures 
in  myopia,  413.  When  there  is  pronounced  insufficiency  of 
the  internal  recti  muscles  a  guarded  tenotomy  of  one  or  both  of 
the  opponent  muscles  may  be  indicated,  413.  Removal  of  the 
crystalline  lens  in  high  myopia  a  procedure  attended  by  con- 
siderable risk,  and  of  doubtful  utility,  413.  Astigmatism,  413. 
Definition  of  the  term,  413.  Regular  astigmatism ,  413.  Com- 
monly due  to  asymmetry  of  the  cornea,  less  often  to  asymmetry  or 
obliquity  of  the  lens,  413.  Usually  a  congenital  and  often  an 
inherited  fault,  413.  Disturbance  of  vision  in  astigmatism,  414. 
Latent  astigmatism,  414.  Explanation  of  the  asthenopia  com- 
monly associated  with  astigmatism,  414.  Improvement  in 
vision  secured  by  nipping  the  lids,  414.  Varieties  of  regular  astig- 
matism, 415.  Simple  astigmatism,  415.  Compound  astigma- 
tism, 41^.  Mixed  astigmatism,  415.  Astigmatism  "accordingto 
the  rule  "  and  "against  the  rule,"  415.  Importance  of  correcting 
even  the  lowest  degrees  of  astigmatism  "  against  the  rule,"  416. 
The  apparent  increase  of  astigmatism  usually  due  to  the  total 
defect  becoming  manifest,  as  a  result  of  correcting  glasses,  416. 
Acquired  astigmatism  commonly  the  result  of  traumatism  or  of 
ulcerative  keratitis,  417.  Astigmatism  capable  of  giving  rise  to 
pronounced  asthenopic  symptoms,  not  incompatible  with  normal 
acuteness  of  vision,  417.  Simple  method  of  detecting  the  pres- 
ence of  astigmatism  marked  in  degree,  417.  Astigmatism  a  prev- 
alent fault,  and  often  a  chief  factor  in  the  causation  not  only 
of  many  ocular  maladies  but  of  many  obscure  disturbances  of 
the  nervous  system,  418.  Treatment  of  astigmatism,  419.  Its 
correction  by  cylindrical  glasses,  419.  These  commonly  bring 
vision  up  to  the  normal  standard,  and,  more  important  still,  by  . 
eliminating  the  previously  existing  accommodative  strain,  do 
away  with  the  asthenopia,  headache,  etc.,  420.  Methods  of 
detecting  and  measuring  astigmatism,  421.  Anisometropia, 
424.  A  not  uncommon  cause  of  asthenopia,  424.  Exception- 
ally it  proves  a  blessing  in  disguise,  424.  Indications  for  its  cor- 
rection by  glasses,  424. 

Anomalies  of  Accommodation. 

Theory  of  the  accommodation  of  the  eye  as  propounded  by 
Helmholtz,  426.  Different  ways  in  which  the  ability  of  the  eye 
to  change  its  focus  may  be  impaired,  427.  Presbyopia  (old- 
sightedness),  427.  Due  to  loss  of  elasticity  of  the  lens,  427. 
Commonly    manifests   itself    about    the    forty-fifth   year,    and 


12  SYNOPSIS    OF    CONTENTS. 

PAGE. 

interferes  with  the  sharp-seeing  of  near  objects,  428.  Its  on- 
coming influenced  by  the  existence  of  refractive  errors,  428. 
Cannot  be  cured  or  its  development  postponed  by  massage,  the 
use  of  "eye-cups,"  etc.,  429.  Glasses  the  only  remedy,  429. 
Fallaciousness  of  the  common  belief  that  the  needed  glasses  can 
be  "fitted"  by  anyone  who  "carries  a  stock"  of  spectacles,  429. 
As  presbyopia  is  a  progressive  condition,  the  glasses  prescribed 
must  be  increased  in  strength  from  time  to  time,  429.  Bifocal 
lenses  in  presbyopia  associated  with  refractive  faults,  430. 
Paralysis  of  the  ciliary  muscle,  430.  Diphtheria  and  syphilis 
the  commonest  causes,  431.  Sudden  impairment  of  near  vision 
the  most  prominent  symptom,  431.  Prognosis  usually  favor- 
able, 431.  Treatment,  432.  Spasm  of  the  ciliary  muscle,  432. 
Commonly  the  result  of  uncorrected  refractive  errors,  432. 
Treatment,  433.  Subnormal  accommodative  power,  433.  A 
not  infrequent  cause  of  asthenopia  in  young  persons,  433.  Due 
to  congenital  lack  of  elasticity  of  the  crystalline  lens  or  to  insuf- 
ficiency of  the  ciliary  muscle,  433.  Rules  for  its  detection  and 
measurement,  435.  Its  treatment  by  convex  glasses  and  by 
spheroprismatic  lenses,  436,  437.  Method  of  determining  the 
required  lenses,  436.  When  associated  with  faults  of  refraction, 
different  glasses  may  be  required  for  far  and  near  vision,  even  in 
quite  young  subjects,  436,  437. 


CHAPTER  XII. 

Muscular  Anomalies  of  the  Eyes 438-479 

Manifest  and  latent  muscular  anomalies,  438.  May  be  of  par- 
alytic or  of  congenital  origin,  or  a  consequence  of  refractive  errors, 
438.  The  manifest  muscular  anomalies — the  actual  squints — not 
provocative  of  eye-strain,  439.  The  latent  muscular  anoma- 
lies—the several  varieties  of  heterophoria — on  the  other  hand, 
commonly  give  rise  to  marked  asthenopic  symptoms,  439. 

Manifest  Muscular  Anomalies. 

Paralytic  squint,  440.  The  nervous  supply  of  the  extrinsic 
ocular  muscles,  440.  Etiology  of  paralytic  squint,  441.  Par- 
alysis of  the  external  rectus  muscle,  442.  Symptoms,  diagnosis, 
and  treatment,  443.  Paralysis  of  the  stiperior  oblique  muscle, 
444.  Paralysis  of  the  oculomotorius,  444.  Oftenest  dependent 
upon  acquired  syphilis,  444.  Varieties,  445.  Frequently  at- 
tended by  ptosis,  445.  Ophthalmoplegia  totalis,  44^.  Ophthal- 
moplegia externa,  445.  Ophthalmoplegia  interna,  445.  Usually 
caused  by  diphtheria,  445.  Treatment  of  the  different  varieties 
of  paralysis  of  the  oculomotorius,  446.  Operative  procedures 
not  to  be  resorted  to  hastily,  446.     Conjugate  ocular  paralyses. 


SYNOPSIS    OF    CONTENTS.  13 

PAGE. 

446.  Nystagmus,  congenital  and  acquired,  447.  Concomitant 
squint,  448.  How  different  from  paralytic  scjuint,  448.  May 
be  constant,  periodic,  or  alternating,  448.  Etiology  of  concomi- 
tant squint,  448.  Amblyopia  of  the  squinting  eye,  449.  Not 
an  example  of  "  amblyopia  exanopsia,  "  449.  Commonly  a  con- 
sequence, not  a  cause,  of  the  squint,  449.  Explanation  of  its  de- 
velopment, 449.  Significance  of  its  regional  character,  450. 
Tests  for  the  detection  of  squint,  452.  Convergent  concomitant 
squint,  453  Develops  in  early  childhood,  453.  The  suf- 
ficiency of  Bonders'  explanation  of  why  many  hypermetropes 
do  not  squint,  453.  Hypermetropia  the  most  important  factor 
in  the  causation  of  convergent  squint,  453.  The  coexistence 
of  insufficiency  of  the  external  recti  muscles  or  of  subnor- 
mal accommodative  power  greatly  increases  the  likelihood 
of  its  occurrence,  454.  Explanation  of  the  occurrence 
of  convergent  squint  in  high  myopia,  454.  Treatment, 
operative  and  non-operative,  of  concomitant  convergent 
squint,  455.  Early  correction  of  the  squint  desirable,  455. 
Established  convergent  squint  seldom  corrected  without  opera- 
tion, 455.  Importance  of  determining  the  refractive  condition 
and  visual  acuteness  in  all  cases  of  squint,  455.  Periodic  conver- 
gent squint  always  capable  of  correction  by  glasses  alone,  456. 
Re-establishment  of  binocular  vision  the  ideal  result  aimed  at  in 
the  treatment  of  squint,  456.  Factors  which  sometimes  render 
this  difficult  of  accomplishment,  456.  Operative  treatment  of 
convergent  squint,  457.  "Tenotomy"  preferable  to  "ad- 
vancement," 457.  Arlt's  method  of  performing  tenotomy  the 
simplest  and  best,  457.  Description  of  his  operation  and 
enumeration  of  the  instruments  required  in  its  performance,  457. 
The  unsightly  sinking  of  the  caruncle  in  awkwardly  executed 
tenotomies  upon  the  internal  rectus,  459.  How  obviated,  459. 
Essential  difference  between  the  modern  operation  of  tenotomy 
and  the  clumsy  procedures  in  vogue  fifty  years  ago,  462.  Di- 
vergent concomitant  squint,  463.  Myopia,  congenital  or  ac- 
quired insufficiency  of  the  internal  recti  muscles,  and  marked 
difference  in  the  visual  acuteness  of  the  eyes  the  most  potent  fac- 
tors in  its  production,  463.  Usually  develops  in  adult  life,  464. 
May  be  present  only  in  near  vision,  464.  Regional  amblyopia,, 
as  observed  in  convergent  concomitant  squint,  rarely  present, 
464.  Treatment,  464.  Exceptional  conditions  which  render 
its  correction,  without  operation,  possible,  464.  Its  correction  in 
high  myopia  often  inadvisable,  465.  Not  so  easily  corrected  by 
tenotomy  as  convergent  squint,  465.  Tenotomy  must  often 
be  supplemented  by  advancement,  465.  Free  tenotomy  of  both 
external  recti  the  best  procedure  in  some  instances,  465.  Ver- 
tical concomitant  squint,  466. 


14  SYNOPSIS    OF    CONTENTS. 


Latent  Muscular  Anomalies. 

Under  this  head  are  included  all  the  varieties  of  heterophoria, 
466.  Less  frequently  encountered  than  refractive  errors,  but 
as  capable  of  producing  the  manifold  symptoms  which  we  have 
learned  to  attribute  to  eye-strain,  466.  When  associated  with 
ametropia,  may  greatly  aggravate  the  ill  consequences  of  the 
refractive  fault,  467.  Exceptionally,  may  have  the  contrary 
effect,  467.  Apparent  and  actual  muscular  anomalies,  467. 
How  they  may  be  distinguished,  467.  Influence  of  refractive 
errors  upon  muscle-imbalance,  467.  Brief  mention  of  the  tests 
employed  for  the  detection  and  measurement  of  heterophoria, 
469.  Importance  of  determining  the  muscle-balance  for  near, 
as  well  as  for  distant,  vision,  469.  Schild's  pin-hole  light,  470. 
Heterophoria  to  be  corrected  by  glasses  or  by  operative  pro- 
cedure, 470.  Exophoria,  471.  Frequently  only  apparent,  and 
dependent  upon  myopia,  472.  Treatment  by  glasses,  tenotomy, 
and,  exceptionally,  by  advancement,  472.  Esophoria,  473. 
Hypermetropia  and  hypermetropic  astigmatism  important  factors 
in  its  causation,  473.  In  ever}'  case  their  existence  should  be 
suspected,  and  carefully  searched  for,  473.  Xot  always  depend- 
ent, however,  upon  these  faults,  474.  Marked  examples  met 
with  in  emmetropia,  474.  Here  there  is  actual  insufficiency  of 
the  external  recti  muscles,  474.  The  tests  for  esophoria  should 
be  appUed  in  near,  as  well  as  in  distant,  vision,  474.  Treat- 
ment, 474.  Exact  determination  of  the  refractive  condition  of 
the  eyes  the  first  step,  474.  If  a  marked  degree  of  hyperme- 
tropia is  present,  it  is  best  to  correct  this  by  glasses  and  postpone 
operative  procedure  until  the  effect  is  observed,  475.  When 
relief  is  not  secured  in  this  way,  prisms  may  be  combined  with 
the  glasses  required  for  the  correction  of  the  refractive  fault  or 
a  tenotomy  performed,  475.  When  no  error  of  refraction  exists 
the  choice  lies  between  prisms  or  a  tenotomy,  and  hinges  upon 
the  degree  of  the  muscle-fault,  475.  Conservatism  to  be  com- 
mended in  operating  for  latent  muscular  anomalies,  476.  But, 
when  the  indications  are  clear,  the  fullest  confidence  may  be  felt 
that  a  well  executed  tenotomy  will  result  in  marked  benefit,  476. 
Bv  "  tenotomy  "  is  meant  a  real  division  of  the  tendon,  476.  Xo 
excuse  for  "graduated"  or  partial  tenotomies,  476.  A  "guarded 
tenotomy"  not  infrequently  indicated,  477.  Actual  squint  often 
corrected  by  less  free  tenotomizing  than  is  sometimes  demanded 
in  latent  muscular  faults,  477.  Hyperphoria,  ^-j-j.  Definition, 
477.  Etiolog},-,  477.  Capable  of  producing  all  of  the  distress- 
ing symptoms  arising  from  eye-strain,  477,  478.  Should  be 
sought  for  in  ever\'  case  of  asthenopia,  478.  Exceptionally  pres- 
ent only  in  near,  or  only  in  distant,  vision.  Should  therefore  be 
sought  for  in  both,  478.     Maddox's  multiple  rod  the  best  test  for 


SYNOPSIS    OF    CONTENTS.  15 


hyperphoria,  478.  In  the  test  for  near  vision,  should  be  used  in 
conjunction  with  the  pin-hole  light  of  Schild,  47S.  Treatment, 
478.  The  lower  degrees  should  be  corrected  by  prisms,  478. 
Operation  indicated  only  when  the  defect  is  pronounced,  478. 

CHAPTER  XIII. 

Injuries  of  the  Eye  and  its  Appendages 480-504 

Injuries  0}  the  eyelids,  480.  May  result  in  malposition  of  the 
lid  margins  and  lacrimal  puncta,  also  in  anchyloblepharon  or 
symblepharon,  480.  Burns  of  the  lids  from  caustic  agents, 
molten  metal,  etc.,  481.  Treatment,  482.  Value  of  Thiersch 
grafts,  483.  Injuries  of  the  bulbar  conjunctiva,  483.  Danger 
of  symblepharon  resulting,  483.  Superficial  injuries  of  the 
cornea,  485.  Usually  not  of  serious  moment  unless  infection 
occurs,  485.  Method  of  applying  carbolic  acid  under  such 
circumstances,  486.  Other  remedial  measures,  486.  Super- 
ficial lodgment  of  foreign  bodies  in  the  eye,  486.  One  of  the  com- 
monest accidents  to  which  the  eye  is  subject,  486.  Nearly  always 
found  adherent  to  the  cornea  or  upon  the  under  surface  of  the 
upper  lid,  487.     Occasionally  find  their  way  into  the  canaliculus, 

488.  Fragments  of  grass  seed  hulls  sometimes  remain  attached 
to  the  cornea  for  months,  488.  Their  true  character  easily  over- 
looked, 488.  Little  reliance  to  be  placed  upon  the  convictions  of 
the  patient  as  to  the  presence  or  non-presence  of  a  foreign  body, 

489.  Best  methods  of  removing  foreign  bodies  from  the  eye,  490. 
Cocain  recjuired  only  when  they  are  adherent  to  the  cornea,  490. 
Contusions  of  the  eye,  4qi.  Though  of  common  occurrence,  sel- 
dom of  serious  moment  because  of  the  protection  afforded  by  the 
bony  orbital  margin  and  the  elastic  cushion  of  fat  upon  which 
the  eyeball  rests,  491.  Rupture  of  the  eyeball,  dislocation  of  the 
lens,  traumatic  cataract,  laceration  of  the  iris,  and  detachment 
of  the  retina  among  the  serious  consecjuences  apt  to  result  from 
severe  contusions,  491.  Commoner  causes  of  such  injuries, 
493.     Treatment  demanded  in  slight  and  in  severe  contusions, 

493.  Penetrating  -wounds  of  the  eye,  494.  Always  of  serious 
concern,  are  made  more  so  because  of  the  danger  of  infection, 

494.  Wounds  of  the  cornea,  iris  and  lens,  494.  Of  the  sclera 
and  ciliary  body,  494.  Of  the  sclera,  choroid,  and  retina,  495. 
Consequences  of  such  injuries,  495.  Treatment,  495.  Anti- 
septic precautions  of  the  first  importance,  495.  Wounds  of  the 
eye  complicated  by  the  lodgment  of  foreign  bodies  within  the  ball, 
497.  Of  still  more  serious  moment,  497.  Much  depends, 
however,  upon  the  nature  of  the  foreign  body  and  upon  its  loca- 
tion, 497.  Least  dangerous  when  sterile  and  when  incapable  of 
undergoing  chemical  change,  497.  May  find  lodgment  in  the 
iris,  the  lens,  the  vitreous  body,  the  deeper  tunics  of  the  eye,  or, 


l6  SYNOPSIS    OF    CONTENTS. 

PAGE. 

more  rarely,  may  fall  into  the  anterior  chamber,  or  pass  through 
the  eye  and  reach  the  depths  of  the  orbit,  498.  Treatment,  499. 
Great  assistance  afforded  by  skiagraphy  and  the  electro-magnet, 
499.  Nowadays,  eyes  often  saved,  and  with  useful  vision, 
which  formerly  were  enucleated  without  hesitation,  499.  Pain 
reaction  test,  500.  Removal  of  non-magnetic  foreign  bodies, 
502.  Difficulties  which  attend  the  removal  of  foreign  bodies 
from  the  anterior  chamber,  502.  Gunshot  wounds,  503. 
Wounds  caused  by  penetrating  foreign  bodies  may  be  of  such  a 
character  as  to  demand  immediate  enucleation  of  the  eye,  504. 
This  is  especially  the  case  when  their  nature  is  such  as  to  render 
the  development  of  sympathetic  ophthalmitis  not  improbable, 
504- 

Appendix 505-520 

Formulae,  for  the  most  part  in  general  use,  of  proved  efficacy 
in  the  treatment  of  diseases  of  tiie  eye,  505. 

Index 521 


PREVALENT  DISEASES  OF 
THE  EYE. 


CHAPTER  I. 


GENERAL  OBSERVATIONS  UPON  THE  DIAGNOSIS 
OF  DISEASES  OF  THE  EYE.  DESCRIPTION  OF 
THE  METHODS  OF  EXAMINING  THE  EYE  AVAIL- 
ABLE TO  THE  GENERAL  PRACTITIONER. 

The  weak  point  of  the  general  practitioner  in  deahng 
with  eye  diseases  is,  unquestionably,  in  reaching  a 
correct  diagnosis;  and  this  is  not  surprising  in  view  of 
the  fact  that  in  most  instances  he  works  without  the 
help  of  the  ophthalmoscope,  the  trial  case,  and  the 
various  contrivances  for  testing  the  central  and  peri- 
pheral visual  acuteness,  the  muscle  balance,  etc.,  aids 
which  the  specialist  in  diseases  of  the  eye  always  has 
at  command,  and  w^ithout  which  even  he  would  often 
be  at  fault.  But,  it  must  be  confessed,  the  general 
practitioner's  errors  of  diagnosis  are  not  always  limited 
to  the  class  of  cases  in  which  these  aids  are  essential. 

For  example,  he  not  infrequently  fails  to  draw  a 
distinction  between  the  several  varieties  of  conjunc- 
tivitis, and,  in  consequence,  is  led  into  errors  in  the 
therapeutic  measures  which  he  employs.  Again,  he 
mistakes  a  corneal  inflammation  or  an  iritis,  with  its 
attendant  conjunctival  injection,  for  a  simple  con- 
junctivitis, with  still  more  serious  consequences;  or, 
in  order  to  avoid  this  mistake,  he  goes   to   the   other 

2  17 


1 8  PREVALENT    DISEASES    OF    THE     EYE. 

extreme,  and  causes  his  patient  much  unnecessary 
inconvenience  bv  prescribmg  atropin  when  only  a  mild 
astringent  is  called  for.  In  other  instances,  he  mis- 
takes the  photophobia,  lacrimation  and  hvperemia  of 
the  conjunctiva  due  to  the  presence  of  a  foreign  body 
upon  the  cornea  or  beneath  the  upper  lid  for  a  com- 
mencing ocular  inflammation,  and  treats  it  accordingly, 
without  success.  A  chronic  conjunctivitis  or  blepharitis, 
dependent  upon  an  error  of  refraction  or  a  muscular 
anomaly  or  secondary  to  disease  of  the  lacrimal 
apparatus,  is  dealt  with  without  reference  to  its  primary 
cause  and,  therefore,  to  no  eflect. 

Still  more  disastrous  in  its  results  is  the  failure  of  the 
general  practitioner  to  recognize  promptly  inflamma- 
tory glaucoma.  Not  infrequently  this  disease  is  mis- 
taken for  iritis  or  keratitis,  and  atropin,  the  remedy 
distinctly  contraindicated,  is  prescribed,  or,  in  the 
quiet  periods  between  the  inflammatory  outbreaks, 
owing  to  the  apparent  or  actual  loss  of  transparency 
of  the  crystalline  lens,  for  cataract,  which  usually  leads 
to  the  patient's  being  advised  to  defer  any  operative 
procedure  until  the  supposed  cataract  is  "ripe." 
Under  such  circumstances,  v/hen  the  case  ultimately 
comes  under  the  observation  of  the  ophthalmic  sur- 
geon the  eye  too  often  is  absolutely  blind,  and  nothing 
that  he  can  do  is  of  avail,  at  least  so  far  as  the  restora- 
tion of  sight  is  concerned.  To  mistake  an  acute 
glaucomatous  attack  for  severe  facial  neuralgia,  as 
sometimes  happens,  though  a  most  unfortunate  mis- 
take, is  less  reprehensible;  for  in  neuralgia  of  the  fifth 
nerve  the  eye  upon  the  affected  side  is  not  infrequently 
injected,  sensitive  to  the  touch  and  photophobic,  and 
the  pain  experienced  in  the  two  conditions  is  of  much 
the  same  character. 


GENERAL    OBSERVATIONS    UPON    DIAGNOSIS.  IQ 

It  is  with  the  view  of  helping  the  generiil  practitioner 
to  avoid  such  mistakes  as  have  been  enumerated  and 
others  of  simihir  character,  and,  further,  to  enable 
him  to  recognize  the  probable  existence  of  other  troubles, 
such  as  retractive  and  muscular  anomalies  and  dis- 
eases of  the  deeper  structures  of  the  eye — as  to  which 
he  can  hardly  be  expected  to  make  a  definite  and  exact 
diagnosis,  and  which,  therefore,  if  he  is  conscientious 
and  discreet,  he  will  not  be  inclined  to  treat — that  this 
chapter  is  written. 

Doubtless,  it  would  be  an  excellent  thing  if  every 
physician  were  an  expert  ophthalmoscopist;  but, 
however  desirable,  there  are  not  many  who  would  con- 
tend that,  for  the  present  at  least,  this  is  practicable. 
As  a  matter  of  fact,  the  number  of  general  practitioners 
at  the  present  day  who  are,  or  who  are  ever  likely  to  be, 
sufficiently  versed  in  the  use  of  the  ophthalmoscope 
to  make  it  of  any  real  diagnostic  value  to  them  is, 
relatively,  so  small  that  it  may  be  treated  as  a  neg- 
ligible quantity.  Such  being  the  case,  it  is  assumed 
throughout  this  work — which,  as  has  been  stated,  is 
designed  solely  for  physicians  engaged  in  general 
practice — that  the  reader  is  not  skilled  in  the  use  of 
the  ophthalmoscope;  and  this  has  materially  modified 
the  treatment  of  several  important  subjects. 

METHODS  OF  EXAMINING  THE  EYE. 
Oblique  Illumination. — Although  skill  in  the  em- 
ployment of  the  ophthalmoscope,  as  has  just  been  said, 
is  not  likely  to  be  acquired  by  very  many  general 
practitioners,  there  is  a  most  valuable  method  of  exam- 
ining the  eye  which  every  physician  can  easily  master, 
and  which  he  w^ill  find  of  the  greatest  possible  assistance 
as  an  aid  to  diagnosis.      I  refer  to  what  is  known  as 


20 


PREVALENT    DISEASES    OF    THE     EYE. 


ohliqiie  illumination  of  the  eye.  A  room  which  can  be 
made,  at  least,  moderately  dark,  a  brightly  burning 
candle,  a  lamp  (a  "student's  lamp"  is  the  best)  or  a 
steadily  burning  gas-light,  and  a  biconvex  lens  of  from 
two  to  two  and  a  half  inches  diameter  and  of  two  and 
a  half  inches  focal  length,  are  all  the  paraphernalia 
necessary,  and  to  employ  these  to  good  purpose  but 


Fig.   I.— Examination  of  the  eye  by  oblique  illumination. 


little  practice  (and  for  this  the  normal  eye  will  suffice) 
is  required. 

"Oblique  illumination"  means,  simply,  the  focusing, 
by  means  of  the  lens  just  described,  of  a  beam  of  arti- 
ficial light  upon  the  anterior  structures  of  the  eye. 
The  examination  is  most  conveniently  made,  as  is  shown 
in  the  accompanying  illustration  (Fig.  i),  by  having 
the  light  to  the  left  and  slightly  in  front  of  the  patient, 
approximately  on  a  level  with  his  eyes,  and  at  a  dis- 


METHODS    OF    EXAMINING    THE    EYE.  21 

tance  of  about  eighteen  inches  from  his  face.  The  lens 
should  be  held  between  the  thumb  and  forefinger  of 
the  examiner,  with  one  of  its  convex  surfaces  towards 
the  light,  the  other  towards  the  eye  to  be  examined,  and 
at  a  distance  of  about  three  inches  from  the  latter. 
The  concentration  of  the  light  upon  the  eye  can  be 
regulated  more  accurately  if  the  examiner  steadies  his 
hand  by  resting  the  ring-finger  upon  the  patient's 
cheek. 

The  great  help  which  this  method  of  inspection 
affords  in  the  investigation  of  abnormal  conditions  in 
the  anterior  structures  of  the  eye — that  is  to  say,  the 
cornea,  anterior  chamber,  iris  and  crystalline  lens — 
can  scarcely  be  realized  by  those  who  have  not  employed 
it.  In  searching  for  foreign  bodies,  whether  lodged 
upon  or  in  the  cornea,  the  iris,  the  lens  or  within  the 
anterior  chamber;  in  ascertaining  the  presence  and 
character  of  opacities  in  the  cornea  or  anterior  portion 
of  the  lens;  in  examining  corneal  abscesses  and  ulcers; 
in  investigating  the  condition  of  the  iris  and  the  pupil, 
determining  whether  suspected  iritis  exists,  whether 
posterior  synechiie  have  formed  or  hypopyon  is  present 
— in  all  these  conditions,  and  in  others  likely  to  be  met 
with  from  time  to  time,  its  value  is  hardly  to  be  esti- 
mated. While,  therefore,  I  do  not  deem  it  worth  while 
to  advise  physicians  in  general  to  endeavor  to  become 
ophthalmoscopists,  I  do  urgently  recommend  that 
every  practitioner  likely  to  be  called  upon  to  give  an 
opinion  regarding  an  injured  or  diseased  eye  should 
provide  himself  with  the  means,  and  acquire  the  easily 
gained  skill,  necessary  to  the  successful  employment  of 
oblique  illumination. 

As  a  further  important  aid  to  accuracy  in  diagnosis, 
every  physician  should  have  at  hand  a  mydriatic  which 


22 


PREVALENT    DISEASES    OF    THE     EYE. 


is  evanescent  in  its  action,  such  as  homatropin  hydro- 
bromate  in  one  per  cent,  solution  or  euphthalmin 
hydrochlorate  in  five  per  cent,  solution;  for,  as  will 
be  seen  later,  by  its  use  he  will  often  gain  valuable  and 
much-needed  information.  He  should,  moreover,  ac- 
quire facility  in  everting  the  upper  lid;  in  determining 
the  tension  of  the  eve;  in  observing  the  pupillary 
reaction,  and  in  testing,  roughly  at  least,  central  and 
peripheral  vision. 
Eversion  of  the  Eyelids. — To  facilitate  eversion  of 


Fig.  2. — Eversion  of  the  upper  lid 
(Hansell  and  Sweet). 


Fig.  3. — Method  of  holding  the 
everted  lid  (Lawson). 


the  upper  lid  the  patient  should  look  stronglv  down- 
ward, without  closing  the  eye.  If  the  exammer  now 
seizes  the  lashes  and  draws  the  lid  aw^ay  from  the  ball 
while  at  the  same  moment  he  depresses  the  upper  edge 
of  the  tarsal  cartilage  either  with  a  finger  of  his  other 
hand  or  a  slender  penholder  or  pencil,  the  eversion  is, 
in  most  instances,  easilv  accomplished  (Figs.  2  and  3). 
The  inner  surface  of  the  lower  lid  mav,  of  course,  be 
inspected  with  more  ease.  Its  eversion  is  effected  by 
having  the  patient  look  upward,  and  by  drawing  the 


METHODS    OF    EXAMINING    THE    EYE. 


23 


margin  of  the  lid  downward  and  pressing  it  against  the 
lower  border  of  the  orbit  with  the  finger-tip. 

Tension  of  the  Eye. — The  intraocular  tension  or 
hardness  of  the  eyeball,  which  varies  greatly  in  different 
affections  of  the  eye,  is  determined  by  having  the 
patient  look  downward  and  making  gentle  pressure 
upon  the  e^^eball,  through  the  upper  lid,  with  the  tip 


Fig.  4. — Pusition  of  hands  in  determining  intraocular  tension. 


of  the  forefinger  or  second  finger  of  each  hand  (Fig.  4). 
The  pressure  should  alternate,  not  too  quickly,  between 
the  two  fingers,  and  should  be  made  well  back  of 
the  corneal  border.  By  allowing  the  ring  or  middle 
finger  of  each  hand  to  rest  upon  the  temple  or  brow 
of  the  patient,  so  as  to  support  the  w^eight  of  the  hand, 
the  test  is  rendered  more  delicate.  In  recording  the 
result  of  such  an  examination  it  is  usual  to  employ  a 


24  PREVALENT    DISEASES    OF    THE     EYE. 

capital  T  as  an  abbreviation  for  "tension,"  -|-T  indi- 
cating increased  tension,  or  an  abnormally  hard  eye- 
ball, — T,  reduced  tension,  and  Tn,  normal  tension. 
The  numerals  i,  2,  3  following  +T  or  — T  are  used  to 
indicate  varying  degrees  of  increased  or  reduced  tension. 

Pupillary  Reaction. — The  patient  should  be  seated 
facing  the  bright  light  of  a  window  (not,  however,  the 
direct  rays  of  the  sun)  and  the  pupillary  reaction  of  each 
eye  should  be  tested  separately,  the  light,  meantime, 
being  carefully  excluded  from  the  other  eye,  which 
should  be  closed  and  covered  by  the  patient's  hand. 
The  patient  having  been  directed  to  look  mto  the 
distance,  the  hand  of  the  examiner  should  be  held  in 
front  of,  and  quite  close  to,  the  eye  under  observation, 
(so  close  to  it  that  the  patient  will  not  attempt  to  look 
at  the  hand — to  "accommodate"  for  it — as  this,  of 
itself,  would  cause  the  pupil  to  contract)  and  then,  after 
the  eve  has  been  shaded  in  this  way  for  a  few  moments, 
the  hand  should  be  removed  quickly,  and  the  behavior 
of  the  pupil  noted. 

Under  normal  conditions  the  pupil,  which  will  have 
dilated  considerably  under  the  shadow  of  the  hand, 
contracts  sharply  and  promptlv  when  the  light  is 
allowed  to  fall  upon  the  e\'e.  This  is  the  direct  reflex 
action  of  the  pupil,  caused  by  contraction  of  the  sphinc- 
ter muscle  of  the  iris.  As  is  well  known,  it  is  due  to 
the  stimulation  of  the  retina  by  the  greater  amount  of 
light  falling  upon  it,  which  leads,  in  turn,  to  stimulation 
of  the  sphincter  pupillae  center  in  the  oculomotor 
nucleus.  The  necessity  for  carefully  excluding  the 
light  from  the  eye  not  under  observation  while  testing 
the  pupillary  reaction  of  the  other  eye  arises  from  the 
fact  that,  normally,  both  pupils  contract  when  the 
retina  of  either  eye  is   stimulated   by  light.     This   is 


METHODS    OF    EXAMINING    THE    EYE.  25 

known  as  the  indirect  or  cotjsensual  reflex  action  of  the 
pupil,  and  is  a  consequence  of  the  semi-decussation  of 
the  optic  nerves  in  the  chiasm.  A  contraction  of  the 
pupils  also  occurs  in  accommodation  (focusing)  of  the 
eyes  for  near  objects  and  in  the  convergence  of  the  visual 
axes  which  usually  accompanies  an  effort  of  accommo- 
dation. This  is  called  the  associated  action  of  the 
pupils. 

Before  describing  the  more  important  alterations  in 
pupillary  reaction  due  to  pathological  conditions,  it  will 
be  well  to  mention  that  both  the  size  and  degree  of 
reaction  to  light  of  the  pupils  vary  greatly  in  persons 
who  are  entirely  free  from  disease.  In  the  first  place, 
in  youth  the  pupils  are  larger  and  respond  more  en- 
ergetically to  light  than  they  do  in  advanced  life. 
Again,  the  size  of  the  pupils  is  influenced  by  the  state 
of  refraction  of  the  eye,  being,  as  a  rule,  smaller  in 
hypermetropic,  and  larger  in  myopic  than  in  normally 
constructed,  or  emmetropic,  eyes.  Frequently,  how- 
ever, the  size  and  activity  of  the  pupils  vary  markedly 
without  assignable  cause,  just  as  the  diameter  of  the 
cornea  or  iris  varies  in  eyes  that  are  entirely  normal. 
In  health  the  pupils  of  the  two  eyes  are  usually  of  the 
same  size,  though  slight  differences  are  not  very  un- 
common, and  are  not  significant.  A  marked  differ- 
ence in  the  refraction  of  the  two  eyes  may  cause  a 
difference  in  the  size  of  the  pupils,  the  pupil  being 
smaller  in  the  eye  in  which  a  greater  accommodative 
effort  is  required.  In  shape  the  pupils  vary  less  than 
in  size,  being,  in  health,  practically  round. 

There  are  many  pathological  conditions  which  in- 
fluence the  size,  shape  and  reactions  of  the  pupils. 
The  iris  itself  may  be  the  seat  of  disease;  for  example, 
iritis  may  be  present,  and  this  commonly  causes  con- 


26  PREVALENT    DISEASES    OF    THE    EYE. 

traction  and  immobility  of  the  pupil  and  not  infre- 
quently distortion,  owing  to  the  formation  of  adhesions 
between  the  ins  and  the  lens  capsule.  On  the  other 
hand,  when  the  tension  of  the  eye  becomes  abnormally 
increased,  as  in  glaucoma,  the  pupil  is  more  or  less 
widely  dilated,  is  often  oval  in  shape,  and  responds 
but  slightly,  if  at  all,  to  light.  Inflammation  of  the 
cornea,  the  presence  of  a  foreign  body  in  the  eye  and, 
in  fact,  almost  any  condition  accompanied  by  photo- 
phobia, lacrimation  and  ciliary  irritation,  if  we  except 
glaucoma,  is  attended  by  contraction  of  the  pupil. 
Again,  a  moderately  dilated  and  immovable  pupil  may 
be  caused  by  paralysis  of  the  sphincter  muscle  of  the 
iris,  which  is  commonly  attended  by  paralysis  of  accom- 
modation, and  may,  or  may  not,  be  accompanied  by 
paralysis  of  the  other  ocular  muscles  supplied  by  the 
third  nerve.  A  ividely  dilated  and  immovable  pupil, 
if  glaucoma  be  excluded,  points  strongly  to  the  influence 
of  a  mydriatic.  Marked  and  persistent  contraction  of 
the  pupil  may  be  due  to  eserin  or  some  other  myotic, 
to  opium  poisoning,  to  disease  of  the  brain  and  its 
meninges,  causing  irritation  of  the  sphincter  pupillae 
center,  to  spinal  lesions,  causing  paralysis  of  the  pupil- 
dilating  center,  or  to  paralysis  of  the  cervical  sympathe- 
tic. A  dilated  pupil  which  responds  sluggishly  or  not 
at  all  to  light,  and  is  accompanied  by  impairment  of 
vision  for  distant  as  well  as  near  objects,  glaucoma  and 
adhesion  of  the  iris  to  the  lens  capsule  being  excluded, 
indicates  loss  or  impairment  of  function  in  the  retina 
or  optic  nerve-tracts. 

It  should  be  remarked,  however,  that  in  rare  in- 
stances, when  a  lesion  exists  high  up  in  the  optic  tract, 
beyond  the  point  where  the  fibers  which  pass  to  the 
pupillary  center  are  given  off^,  the  pupil  may  react  to 


METHODS    OF    EXAMINING    THE    EYE.  27 

light  though  absolute  blindness  be  present.  The 
opposite  condition,  in  which  the  pupil  fails  to  react 
to  light  though  good  vision  exists,  is  frequently  met  with 
in  the  early  stages  of  tabes  dorsalis.  When,  under  such 
circumstances,  the  reaction-  of  the  pupil  to  accommo- 
dation and  convergence  is  retained  we  have  what  is 
known  as  the  Argyll-Robertson  symptom,  due  to  a 
lesion  involving  the  fibers,  just  mentioned,  which  pass 
from  the  optic  tract  to  the  center  for  pupillary  move- 
ments. Usually  the  reflex  immobility  of  the  pupil  met 
with  in  tabes  dorsalis  is  associated  with  myosis,  but 
exceptionally  the  pupil  may  be  of  normal  size  or  even 
abnormally  dilated. 

Determination  of  Acuteness  of  Vision. — To  de- 
termine the  visual  acuteness  for  distant  objects  it  is  cus- 
tomary to  employ  capital  letters  of  different  sizes,  which 
are  printed  upon  a  sheet  of  paper  or  upon  cardboard. 
The  test-letters  suggested  by  Snellen  (which  are  to  be 
had  of  most  opticians)  are  those  commonly  employed. 
The  largest  of  Snellen's  letters,  designated  by  the 
Roman  numeral  CC,  is  of  such  size  that  it  should  be 
recognized  by  an  eye  having  normal  sight  at  two 
hundred  feet.  The  letters  next  smaller  should  be  dis- 
tinguished at  one  hundred  feet,  and  finally  there  are 
letters  recognizable  at  only  fifteen  feet,  which  is  as 
small  as  is  usually  required  for  testing  distant  vision. 
If  practicable,  the  letters,  with  a  good  light  falling  upon 
them,  should  be  placed  twenty  feet  from  the  patient; 
but  whatever  the  distance  it  should  be  known,  if  the 
test  is  to  be  of  even  approximate  accuracy.  The  sight 
of  each  eye  should  be  determined  separately,  the  other 
eye  being  "excluded"  by  holding  a  card  or  other 
opaque  object  before  it.  If  at  twenty  feet  the  letters 
in   the    row    marked    XX,   or    if   at   fifteen   feet  those 


28  PREVALENT    DISEASES    OF    THE     EYE. 

marked  XV,  can  be  distinguished,  vision  (abbreviated 
"V")  is  practically  normal,  and  is  recorded  thus: 
V  ^^  £^  or  Yv,  as  the  case  may  be.  If,  however, 
at  twenty  feet  only  the  letters  which  should  be  recog- 
nized at,  let  us  say,  fifty  feet  are  distinguished,  such  a 
subnormal  acuity  of  sight  would  be  noted  as  V  =  ^. 
Sometimes  it  will  happen  that  not  even  the  largest 
letter  can  be  made  out  at  the  usual  testing  distance, 
and  then  it  will  be  necessary  to  lessen  the  distance, 
until  finally,  at  six  feet,  perhaps,  it  can  be  distinguished, 
when  the  record  would  be  V  =  ^. 

When  the  impairment  of  vision  is  still  more  marked, 
the  patient  may  be  placed  with  his  back  to  the  light,  and 
his  ability  to  count  fingers  ascertained.  In  making  this 
test  the  examiner  holds  up  one  hand,  with  the  fingers  sep- 
arated, and  slowly  approaches  the  patient  until  he  can 
state  correctly  the  number  of  fingers  extended.  If  three 
feet  should  be  the  greatest  distance  at  which  he  can  do 
this, the  record  would  be:  "Fingers  (or  Fingers  counted) 
at  3  feet."  If  he  is  unable  at  any  distance  to  tell  how 
many  fingers  are  held  up,  we  next  try  whether  he  can 
distinguish  the  movements  of  the  hand  by  reflected 
light  (his  back  being  still  to  the  source  of  illumination, 
usually  a  window).  When  even  this  is  impossible,  he 
may  still  have  "light  perception";  that  is,  he  may  be 
able,  when  facing  the  light,  to  tell  when  the  hand  is  held 
in  front  of  the  eye  and  when  it  is  removed. 

For  testing  7iear  vision — ability  to  see  at  the  usual 
reading  or  seu'ing  distance — the  test-types  of  jaeger  are 
commonly  used.  These  consist  simply  of  sentences 
printed  in  letters  of  different  sizes,  varying  from  No.  i, 
"diamond"  type,  to  No.  24,  in  which  the  letters  are 
nearly  an  inch  and  three-fourths  in  height.  The 
smallest  type  which  the  patient  is  able  to  read  is  as- 


METHODS    OF     EXAMINING    THE     EYE.  29 

certained,  and  the  result  is  noted  as  J.  (or  Jaeger)  No. 
I,  No.  6,  No.  24,  as  the  case  may  be.  In  this  test,  as 
in  the  test  for  distant  vision,  the  eyes  should  be  ex- 
amined separately,  and  the  patient  should  be  seated 
with  his  back  to  the  light. 

For  testing  accurately  eccentric  vision — determining 
the  ''  field  of  vision'' — a  perimeter  (Fig.  5)  is  required; 
but  any  considerable  defect  or  contraction  of  the  visual 
field  may  be  detected  in  the  following  manner:  Let  the 
patient,  with  his  back  to  the  light,  sit  facing  the  ex- 
aminer, at  a  distance  of  about  two  feet,  and,  having 
closed  one  of  his  eyes,  have  him  with  the  eye  under 
examination  look  at  the  open  eye  of  the  examiner  (who 
also  should  close  one  eye,  the  right  if  he  is  testing  the 
patient's  right  eye  and  vice  versa).  Watching  the 
patient  to  see  that  he  does  not  change  the  direction  of 
his  gaze,  the  examiner  now  moves  his  hand  from 
different  parts  of  the  periphery  toward  the  center  of 
the  visual  field,  and  in  a  plane  about  midway  between 
his  own  and  the  patient's  face.  Using  his  own  field  of 
vision  as  a  standard  of  comparison,  and  requiring  the 
patient  to  tell  the  number  of  fingers  he  extends,  and 
whether  they  are  held  still  or  moved,  the  examiner  is 
able,  in  a  few  moments,  to  determine  whether  the 
eccentric  vision  of  the  patient  is  defective,  whether,  in 
any  direction,  his  field  of  vision  falls  appreciably  short 
of  what  it  should  be.  By  this  method  of  examination 
such  conditions  as  hemianopsia,  the  contraction  of  the 
field  of  vision  characteristic  of  glaucoma,  and  that 
which  occurs  in  detachment  of  the  retina,  in  retinitis 
pigmentosa,  etc.,  may  be  readily  detected. 

In  examining  the  eyes  with  a  view  to  reaching  a 
correct  diagnosis  it  is  of  the  first  importance  that  the 
examination    should    be    conducted    in    a    systematic 


30 


PREVALENT    DISEASES    OF    THE     EYE. 


oooo 


Fig.  5. — Standard  registering  perimeter.  The  examination  may  be 
made  with  the  carrier  which  moves  along  the  semicircle,  or  the  test-object 
may  be  carried  along  this  by  means  of  dark  discs  attached  to  a  long  handle, 
each  disc  containing  in  its  center  the  test -object.  The  patient's  chin  is 
placed  in  the  curved  chin-rest;  the  notched  end  of  the  upright  bar  is  brought 
in  contact  with  the  face,  directly  beneath  the  eye  to  be  examined,  which 
attentively  fixes  the  center  of  the  semicircle.  The  other  eye  should  be 
covered,  preferably  ^^^th  a  neatly-adjusted  bandage.  The  record-chart 
is  inserted  at  the  back  of  the  instrument,  and  by  means  of  an  ivory  ver- 
nier the  examiner  is  enabled  to  mark  exactly  with  a  pencil  the  point  on  the 
chart  corresponding  to  the  position  on  the  semicircle  at  which  the  patient 
sees  the  test-object.  The  various  marks  are  then  joined  by  a  continuous 
line,  and  a  map  of  the  field  is  obtained. 


METHODS    OF    EXAMINING    THE     EYE.  31 

manner.  Although  the  patient's  account  of  his  malady 
is,  more  often  than  not,  indefinite  and  unsatisfactory 
and  not  infrequently  misleading,  it  should  be  elicited 
at  the  outset;  and  if  there  is  any  reason  to  suspect  that 
the  eye  affection  is  dependent  upon  a  constitutional 
cause  this  too  should  be  carefully  inquired  into.  How 
long  have  the  eye  synipto/ns  lasted  is  a  most  important 
question,  which,  if  intelligently  answered,  will  probably 
afford  the  examiner  more  assistance  than  any  other 
one  inquiry.  Other  important  questions  are,  as  to  the 
existence  of  pain,  photophobia,  lacrimation,  discharge 
(gumming  of  the  lashes  during  sleep),  and  impairment 
of  sight.  In  mquiring  as  to  the  last  mentioned  symp- 
tom it  is  essential  that  we  should  learn  whether  vision 
is  defective  for  distant  objects  only,  or  for  near  objects 
only,  or  whether  both  are  seen  indistinctly,  also  whether 
diplopia  exists. 

The  answers  to  these  questions  should  give,  at  least, 
a  clue  as  to  what  to  look  for  when  the  next  step  in  the 
examination — the  careful  inspection  of  the  eye  by  day- 
light— is  begun.  The  existence  of  pain,  at  all  pro- 
nounced, for  example,  would  suggest  the  probability  of 
inflammation  of  the  cornea,  iris,  or  ciliary  body  being 
present,  or,  perhaps,  glaucoma,  or  a  foreign  body  or 
other  traumatic  lesion.  Marked  photophobia  and 
lacrimation,  usually  coexistent  with  pain,  have  a  like 
significance.  Considerable  muco-purulent  or  purulent 
discharge  is  indicative  of  inflammation  of  the  conjunc- 
tiva, which,  except  in  the  more  severe  types,  such  as 
gonorrheal  conjunctivitis,  is  not  usually  attended  by 
pain,  but  rather  by  a  sensation  of  irritation,  as  though 
"sand  were  in  the  eyes."  Again,  if  the  symptoms 
(impaired  vision,  irritability  of  the  eyes,  etc.)  have 
lasted  but  a  few  days,   one  may   put  aside  errors  of 


32  PREVALENT    DISEASES    OF    THE     EYE. 

refraction  and  muscular  anomalies,  and  search  for  a 
distinctly  acute  affection.  A  history  of  declining 
vision,  without  pain  or  external  signs  of  inflammation, 
especially  in  a  person  beyond  middle  life,  would  point 
to  cataract  or,  this  being  excluded,  to  disease  of  the 
retina  or  optic  nerve.  The  existence  of  syphilis, 
nephritis,  diabetes,  alcoholism,  or  arteriosclerosis  is 
especially  significant  in  this  connection.  Photophobia, 
it  should  be  remarked,  is  not,  as  might  be  supposed, 
a  usual  symptom  of  retinitis  or  neuritis. 

Epiphora  of  long  standing  suggests  stricture  of  the 
lacrimal  duct  or  canaliculi,  or  malposition  or  occlusion 
of  the  lacrimal  puncta,  and  should  lead  to  a  careful 
examination  of  these  structures.  Poor  vision  for  near 
objects,  as  in  reading,  with  good  distant  vision,  indi- 
cates failure  or  loss  of  the  accommodative  power  of  the 
eye,  and  in  middle  life  usually  means  presbyopia;  in 
childhood  or  early  life,  especially  if  occurring  suddenly, 
paralysis  of  the  ciliary  muscles,  as  from  diphtheria. 
A  sudden  onset  of  photophobia,  lacrimation,  and  con- 
junctival injection,  especially  when  limited  to  one  eye, 
suggests  the  presence  of  a  foreign  body,  which  should 
be  carefully  looked  for,  even  though  the  patient  is  not 
aware  of  its  entrance. 

Long-continued  discomfort  in  the  eyes  (asthenopia), 
usually  more  marked  after  near  work,  and  which  may 
or  may  not  be  accompanied  by  imperfect  sight;  head- 
aches, frontal  or  occipital,  precipitated  by  reading, 
sewing  or  gazing  fixedly  at  distant  objects;  chronic 
inflammation  of  the  lid  margins  (blepharitis  margina- 
lis),  without  other  signs  of  constitutional  disorder,  and 
persistent  hyperemia  of  the  conjunctiva,  indicate  re- 
fractive errors,  and  less  frequently  muscular  anomalies, 
and  call  for  carefully  adjusted  glasses.     If,  under  such 


METHODS    OF    EXAMINING    THE    EYE.  ^^ 

circumstances,  there  is  good  near  vision  and  poor 
vision  for  distance,  near-sightedness  (myopia)  probably 
exists;  if  both  near  and  far  vision  are  poor,  hyperme- 
tropia  of  high  grade  or  astigmatism.  AbiHty  to  read 
ordinary  print  at  the  usual  reading  distance,  it  should 
be  remarked,  does  not  exclude  myopia,  but  only  myopia 
of  high  grade.  Inability  to  obtain  satisfactory  glasses 
at  the  usual  presbyopic  age  (about  forty-five)  suggests 
difference  in  the  refraction  ot  the  eyes,  astigmatism  or 
a  muscular  error.  Diplopia  of  sudden  onset,  often 
but  not  aWays  attended  by  an  evident  squint,  is  com- 
monly due  to  paralysis  of  one  or  more  of  the  extrinsic 
eye  muscles.  Squint  of  long  standing  (rarely  attended 
by  diplopia),  though  it  may  have  had  its  origin  in  an 
old  paralysis,  usually  indicates  the  existence  of  a  refrac- 
tive error  of  high  grade. 

Although  it  seems  almost  incredible,  it  occasionally 
happens  that  the  sight  of  one  eye  is  lost,  and  monocular 
blindness  exists  for  weeks  or  months,  without  the  in- 
dividual being  conscious  of  the  fact.  When,  under  such 
circumstances,  the  discovery  is  finally  made,  the  ac- 
count usually  given  by  the  patient  is  that  the  loss  of 
sight  has  only  just  occurred.  The  knowledge  that  such 
a  thing  is  possible  may  prevent  much  perplexity  in 
reaching  a  correct  diagnosis.  It  is  well,  moreover,  to 
bear  in  mind  that,  in  general,  the  statements  of  patients 
as  to  the  amount  of  sight  they  possess,  particularly  if 
the  impairment  of  vision  is  limited  to  one  eye,  are  often 
misleading.  Influenced  by  especial  considerations,  they 
may  claim  to  have  better  vision  than  they  really  possess; 
but  commonly  they  go  to  the  other  extreme,  and  des- 
cribe the  loss  of  sight  as  being  more  complete  than  is 
actually  the  case.  The  patients  themselves  are  often 
surprised  to  find  their  own  convictions  so  much  at 
3 


34  PREVALENT    DISEASES    OF    THE     EYE. 

fault;  but  occasionally  it  is  evident  that  they  are 
wilfully  attempting  to  deceive  the  examiner. 

Inspection  of  the  Eye  by  Daylight. — Guided  by 
the  information  gained  by  the  questions  which  have 
been  enumerated,  the  examiner  should  next  proceed  to 
a  careful  inspection  of  the  lids  and  the  superficial 
structures  of  the  eye.  A  single  glance  may,  in  some 
instances,  suffice  to  confirm  beyond  doubt  the  tentative 
diagnosis  already  made,  perhaps,  as  a  result  of  these 
questions;  but,  at  all  events,  the  examination  will 
seldom    fail    to    afford    distinctly    helpful    information. 

As  a  matter  of  routine,  it  will  be  well  to  glance  at  the 
lids,  to  see  whether  they  are  swollen,  whether  their 
position  and  movements  are  normal,  their  margins 
free  from  inflammation,  and  whether  the  eyelashes 
occupy  their  proper  position  and  are  neither  deficient 
in  number  nor  matted  together  by  discharge.  If 
there  is  a  history  of  epiphora  the  position  and  pervious- 
ness  of  the  lacrimal  puncta  should  be  observed,  and 
pressure  should  be  made  upon  the  lacrimal  sac;  for 
if  there  is  occlusion  of  the  nasal  duct  there  will  almost 
surely  be  an  accumulation  of  tears  and  mucus  in  the 
sac,  and  the  pressure  exerted  by  the  finger  will  cause 
regurgitation  through  the  lacrimal  puncta.  If  for  any 
reason  it  is  desirable  to  inspect  the  inner  surface  of  the 
lids — to  search,  for  example,  for  a  foreign  body  or  to 
observe  the  condition  of  the  palpebral  conjunctiva — 
they  should  be  everted  in  the  manner  already  described. 

Next  an  examination  of  the  eye  itself  should  be  made, 
and  this  should  include  a  determination  of  the  tension 
(T)  of  the  ball,  a  careful  inspection  of  the  conjunctiva, 
with  reference  to  injection  and  the  presence  of  dis- 
charge, of  the  smoothness  of  the  surface  and  the 
transparency  of  the  cornea,  of  the  color  and  appearance 


METHODS    OF    EXAMINING    THE    EYE.  35 

of  the  iris,  of  the  size,  shape,  blackness,  and  reaction  of 
the  pupil,  of  the  depth  of  the  anterior  chamber,  and  of 
the  clearness  of  the  aqueous  humor.  The  movements 
of  the  eyes,  binocular  as  well  as  monocular,  should 
also  be  observed,  especially  if  diplopia  is  complained 
of  or  strabismus  is  suspected.  This  may  be  done 
conveniently  by  means  of  a  pencil,  held  fifteen  inches 
from  the  eyes  and  moved  in  various  directions,  or  a 
lighted  candle  at  the  distance  of  as  many  feet.  The 
sensibility  of  the  cornea,  when  glaucoma  or  paralysis 
of  the  ciliary  nerves  is  suspected,  should  be  determined 
by  touching  its  surface  lightly  with  a  spill  of  tissue  paper 
or  absorbent  cotton. 

The  presence  of  marked  opacity  of  the  crystal- 
line lens,  especially  if  the  opacity  involves  the 
anterior  cortical  layers,  may  usually  be  detected  by 
simple,  daylight  inspection;  but  if  it  is  limited  to 
the  deeper  cortical  layers,  to  the  nucleus,  or  to  the 
periphery  of  the  lens,  or  if  the  cataract,  though  fully 
formed,  be  amber-colored,  it  may  easily  escape  de- 
tection. On  the  other  hand,  it  should  be  remarked  that, 
owing  to  the  greater  amount  of  light  reflected  by  the 
crystalline  lens  in  persons  advanced  in  life,  a  mistaken 
impression  that  a  cataract  is  present  is  often  gained 
by  mere  daylight  inspection,  which  is  dispelled  by  a 
glance  into  the  eye  with  the  ophthalmoscope. 

When  vascular  injection  of  the  eye  is  present  much 
information  may  be  gained  by  carefully  noting  the 
character  of  the  hyperemia.  A  diffuse  injection  of  the 
conjunctiva,  least  pronounced  near  the  corneal  limbus, 
of  a  brick-red  color,  the  injected  vessels  being  large, 
tortuous,  and  movable,  is  indicative  of  an  inflammation 
limited  to  the  conjunctiva.  On  the  other  hand,  a  zone 
of  pericorneal  injection,  pinkish  in  color,  composed  of 


36  PREVALENT    DISEASES    OF    THE     EYE. 

fine,  subconjunctival  vessels,  usually  radiating  from  the 
corneal  border,  is  of  more  serious  import,  and  points  to 
keratitis,  iritis,  cyclitis,  inflammatory  glaucoma  or,  per- 
haps, to  the  presence  of  a  foreign  body  upon  the  cornea  or 
beneath  the  upper  lid. 

The  character  and  amount  of  the  discharge  from 
the  eye  are  also  of  diagnostic  value.  In  the  milder 
conjunctival  inflammations  the  discharge  is  mucoid  or 
muco-purulent  in  character  and  slight  in  amount, 
manifestmg  itself  chiefly  by  gumming  the  lashes 
together  during  sleep;  in  the  severer  types  of  con- 
junctivitis, more  especially  in  gonorrheal  ophthalmia, 
it  is  very  profuse  and  distinctly  purulent,  and  a  usual 
accompaniment  is  marked  edema  of  the  lids;  in 
keratitis,  iritis,  and  inflammatory  glaucoma  the  dis- 
charge, due  to  excessive  lacrimation,  is  watery,  with 
but  a  slight  admixture  of  mucus.  It  is  a  good  rule  in 
all  inflammatory  aff'ections  of  the  eyes,  especially  when 
met  with  in  persons  over  forty  years  of  age,  to  test  the 
intraocular  tension,  or,  in  other  words,  to  be  on  the 
lookout  for  glaucoma;  for,  as  has  been  said  already, 
no  more  unfortunate  mistake  can  be  made  than  to  over- 
look the  existence  of  this  disease. 

Inspection  of  the  Eye  by  Oblique  Illumination. — 
Having  completed  the  examination  of  the  eye  by 
daylight,  if  the  diagnosis  is  still  in  doubt  or  further 
information  bearing  upon  the  treatment  of  the  case  is 
needed,  the  inspection  of  the  eye  by  oblique  illumina- 
tion, with  or  without  the  aid  of  a  mydriatic,  should  next 
be  undertaken.  In  the  manner  already  described,  by 
concentrating  the  light  first  upon  one  and  then  upon  an- 
other of  the  superficial  structures  of  the  eye,  the  cornea, 
anterior  chamber,  aqueous  humor,  iris,  and  lens  should 
be    carefully    scrutinized.      In    examining    the    cornea 


METHODS    OF    EXAMINING    THE    EYE.  ^"^ 

one  should  look  for  disturbance  of  the  epithelium, 
loss  of  substance,  diminished  transparency,  superficial 
or  deep,  the  deposition  of  exudates  upon  its  inner 
surface,  and  the  possible  presence  of  a  foreign  body. 
In  inspecting  the  anterior  chamber  one  should  consider 
its  depth,  the  clearness  of  the  aqueous  humor,  and  the 
existence  of  hypopyon.  The  iris  should  be  examined 
for  alterations  in  color  (as  compared  with  the  iris  of  the 
opposite  eye),  for  swelling  of  its  tissue,  for  inflammatory 
exudates,  changes  in  position,  and  for  the  existence  of 
anterior  or  posterior  synechiae.  We  may  also  examine 
by  this  method  the  size  and  shape  of  the  pupil,  its  re- 
action to  light  and  its  clearness. 

If  we  suspect  iritis  and  the  presence  of  posterior 
synechiae,  but  owing  to  the  small  size  of  the  pupil  are  left 
in  doubt,  or  if  we  wish  to  examine  the  lens  for  commenc- 
ing opacity,  a  mydriatic  will  afford  the  greatest  possible 
assistance.  A  delay  of,  perhaps,  fifteen  minutes  will  be 
necessitated;  but  in  the  former  case,  if  our  suspicions 
are  well  founded,  we  shall  obtain  an  irregularly  dilated 
pupil,  showing  plainly  the  synechiae,  and  so  putting  the 
question  of  iritis  beyond  doubt;  and  in  the  latter,  nearly 
the  whole  anterior  surface  of  the  lens  will  be  exposed  to 
view,  and  opacities  will  be  readily  detected,  which  before 
could  not  be  seen.  As  has  been  pointed  out,  a  mydri- 
atic transient  in  its  effect,  such  as  homatropin  or 
euphthalmin,  is  best  adapted  for  this  purpose. 


CHAPTER  II. 

GENERAL  OBSERVATIONS  UPON  THE  TREATMENT 
OF  DISEASES  OF  THE  EYE. 

In  the  management  of  eye  diseases,  a  correct  diag- 
nosis having  been  reached,  the  selection  of  the  proper 
remedy  to  meet  the  condition  is  not  usually  a  difficult 
matter,  even  for  those  who  have  not  paid  especial 
attention  to  this  branch  of  medicine.  This  is  so  be- 
cause, in  the  first  place,  the  indications  are  usually 
definite  and  clear  and,  in  the  next  place,  the  list  of 
available  remedies  is  not  a  long  one. 

In  writing  for  the  general  practitioner  there  is,  per- 
haps, less  reason  than  there  would  be  in  addressing  the 
specialist  in  ophthalmology  to  emphasize  the  fact  that 
eye  diseases  should  not  be  treated  simply  as  local 
maladies,  and  that  in  their  management  constitutional 
remedies  are  at  times  even  more  important  than  local 
ones.  There  are,  of  course,  diseases  of  the  eye  which 
are  purely  local  affections,  and  which  demand  only 
local  treatment;  but  there  are  many  others  which  are 
but  local  manifestations  of  a  constitutional  disorder, 
and  in  which  general  measures,  aimed  at  this  disorder, 
are  an  essential  part  of  their  successful  treatment. 

To  enumerate  all  the  drugs  and  therapeutic  agents 
apt  to  be  needed  in  treating  the  commoner  diseases  of 
the  eye  is  not  a  difficult  task,  and  the  list  need  not  be 
a  long  one.  It  would  naturally  be  divided  into  local 
remedies  and  constitutional  remedies.  Such  a  list, 
fairly  comprehensive,  would  be  as  follows: 

38 


GENERAL    OBSERVATIONS     UPON    TREATMENT. 


39 


Zinc  sulphate, 
Boracic  acid, 
Mercury  bichlorid, 
Sodium  chlorid. 
Silver  nitrate, 
Protargol,  or 
Argyrol, 

Copper  sulphate, 
Chlorin  water, 
Carbolic  acid, 
Salicylic  acid. 
Yellow  oxid  of  mercury, 
Alum, 
Zinc  oxid. 
Caustic  potash. 
Mercurial  ointment, 
Atropin  sulphate, 
Eserin  sulphate. 


LOCAL  REMEDIES. 

Pilocarpin  hydrochlorate, 

Holocain  hydrochlorate, 

Hyoscyamin  hydrobromate, 

Homatropin  hydrobromate,  or 

Euphthalmin  hydrobromate, 

Cocain  hydrochlorate. 

Adrenalin, 

Dionin, 

Tincture  of  iodin, 

Extract  of  opium. 

Extract  of  belladonna, 

Castor  oil, 

Veratrin  oleate, 

Jequirity, 

Cold  (ice-cloths). 

Heat  (dry  or  moist), 

Galvano-cautery, 

Local  bloodletting  (leeching). 


CONSTITUTION 
Mercury  biniodid. 
Mercury  protoiodid, 
Mercury  bichlorid. 
Calomel, 

Mercurial  ointment. 
Potassium  iodid, 
Quinin  sulphate. 
Strychnin  sulphate. 
Extract  or  tincture  of  nux  vomica. 
Iron  phosphate. 
Iron  iodid. 
Iron  carbonate. 
Opium, 
Morphin  sulphate. 


AL  REMEDIES. 

Pilocarpin  hydrochlorate. 

Arsenic  (Fowler's  solution), 

Lithium, 

Colchicum, 

Cod-liver  oil. 

Sodium  pyrophosphate, 

Trional, 

Phenacetin, 

Diphtheria  antitoxin. 

An  energetic  purgative  (such  as 
the  "compound  calomel  pow- 
der," mentioned  in  the  ap- 
pendix). 


Speaking  broadly,  it  may  be  said,  as  to  local  remedies, 
that  astringents  and  antiseptics  are  indicated  when 
there  is  a  considerable  discharge  from  the  eye  of  mucus 


40  PREVALENT    DISEASES    OF    THE     EYE. 

or  pus,  such  discharge  being  indicative  of  inflammation 
of  the  conjunctiva.  On  the  other  hand,  the  existence 
of  pain,  photophobia,  and  lacrimation,  symptoms 
characteristic  of  keratitis,  iritis,  etc.,  commonly  con- 
traindicates  their  employment  and  calls  for  soothing 
remedies,  especially  atropin  (unless  there  is  +  T  of 
the  eye)  and  opium.  As  the  diff'erent  varieties  of  in- 
flammation of  the  conjunctiva,  if  we  except  phlyctenular 
and  diphtheritic  conjunctivitis,  are  essentially  local 
affections,  it  is  evident  that  the  field  for  astringents 
and  antiseptics  is  mainly  in  local  maladies.  Atropin, 
on  the  other  hand,  while  useful  in  certain  purely  local 
affections,  as,  for  example,  corneal  ulcer  due  to  direct  in- 
fection, is  more  especially  indicated  in  inflammations  of 
the  eye  which  have  a  constitutional  origin,  such  as  iritis, 
cyclitis,  and  phlyctenular,  herpetic,  and  interstitial 
keratitis. 

In  no  department  of  medicine  are  an  early  diagnosis 
and  a  prompt  employment  of  remedial  measures  more 
important  than  in  ophthalmic  practice.  Especially  is 
this  true  in  the  treatment  of  purulent  (gonorrheal)  con- 
junctivitis, of  diphtheritic  conjunctivitis,  of  iritis  and 
of  inflammatory  glaucoma.  In  the  first  named  affec- 
tion, and  the  observation  applies  as  well  to  diphtheritic 
conjunctivitis,  a  delay  of  two  or  three  days  may  mean 
loss  of  sight  through  necrosis  of  the  cornea;  in  iritis 
it  may  mean  a  permanently  damaged  eye  through  the 
formation  of  unbreakable  posterior  synechia?,  while 
in  the  severer  types  of  acute  glaucoma  a  still  briefer 
delay,  of  twenty-four  or  forty-eight  hours,  may  result 
in  absolute  blindness  from  irreparable  damage  to  the 
optic  nerve  and  retina. 

Local  Remedies. — Topical  remedies  for  the  eye 
are   commonly   in   the   shape   of  collyria — solutions  in 


GENERAL    OBSERVATIONS    UPON    TREATMENT.  4I 

water  of  various  drugs  for  instillation  into  the  con- 
junctival sac;  lotions,  to  be  applied  on  linen  or 
gauze  pads  to  the  closed  lids;  ointments,  for  application 
to  the  eye  itself  or  to  the  lids;  powders,  to  be  dusted 
into  the  eye,  and  crystals  or  crayons  (copper  sul- 
phate, alum,  silver  nitrate)  for  direct  application  to 
the  eye,  usually  to  the  palpebral  conjunctiva  or  to 
the  lids.  Strong  antiseptic  agents,  such  as  pure  car- 
bolic acid  and  tincture  of  iodin,  are  applied  accu- 
rately and  in  small  quantities  to  threatening  corneal 
ulcers,  and  the  actual  cautery — the  galvanocautery 
being  best  adapted  to  the  purpose — is  similarly  em- 
ployed. Heat  and  cold,  the  former  in  the  shape  of  hot 
fomentations  or  dry  heat  (Japanese  stove),  the  latter  in 
the  form  of  ice-cloths  or  small  ice-bags,  are  also  used. 
Ice-cloths,  which  are  especially  useful  in  gonorrheal 
ophthalmia,  should  be  kept  lying  upon  a  block  of  ice, 
from  which  they  must  be  transferred  at  brief  intervals 
to  the  lids  of  the  affected  eye.  Moist  heat  may  be 
conveniently  applied  by  means  of  a  soft,  bird's-nest- 
shaped  sponge,  which  should  be  kept  at  the  desired 
temperature  by  being  repeatedly  dipped  in  hot  water. 

For  the  application  of  collyria  an  eye-dropper  is 
essential,  and  one  with  a  bent  nozzle  is  more  convenient 
than  a  straight  one  (Fig.  6  and  Fig.  7).  As  it  is  pos- 
sible to  transfer  infectious  material  from  one  eye  to 
another  by  means  of  eye-droppers,  certain  precautions 
should  be  observed  in  their  use.  The  danger  of  doing 
this  is  slight  if  the  dropper  is  not  allowed  to  come  in 
contact  with  the  lids  or  eye,  which,  of  course,  need  not, 
and  should  not,  happen.  It  is  best,  however,  in  the 
management  of  distinctly  contagious  diseases — such  as 
gonorrheal  conjunctivitis — that  a  special  dropper  should 
be  set  apart  for  each  case,  and  this  should  not  be  used 


42 


PREVALENT    DISEASES    OF    THE     EYE. 


for   another   patient   unless   it   has   been   steriHzed    bv 
boiHng.      It   is   important    also   that    a    dropper   which 


1 


Fig.  6. — The  right  \va\-  to  hold  an  eye-dropper. 


I 


Fig.  7. — The  wTong  way  to  hold  an  eye-dropper. 

has  been  used  for  a  mydriatic — atropin,  for  example — 
should  not  be  used  for  the  instillation  of  other  collvria, 


GENERAL    OBSERVATIONS     UPON    TREATMENT.  43 

as  neglect  of  this  precaution  may  result  in  a  dilatation 
of  the  pupil  and  a  blurring  of  vision  that  will  cause  the 
patient  much  needless  inconvenience. 

As  a  rule,  to  apply  more  than  one  or  two  drops  to 
the  eye,  as  is  often  done,  is  unnecessary,  since  hardly 
that  quantity  is  retained  in  the  conjunctival  sac,  and 
in  the  case  of  poisonous  solutions — atropin,  hyoscyamin 
and  the  like — it  is  especially  to  be  avoided,  as  general 
intoxication  may  be  induced  in  this  way.  It  is  not 
uncommon  for  individuals  to  "taste"  such  medicines 
as  those  just  mentioned  shortly  after  their  application 
to  the  eye,  indicating  that  they  have  passed  through 
the  lacrimal  passages  and  have  reached  the  nose  and 
pharynx.  It  is  in  this  way  that  they  impress  the  system, 
and  for  this  reason  it  is  better  that  poisonous  collyria 
should  be  instilled  near  the  outer,  rather  than  near  the 
inner,  canthus.  If  it  is  desirable  that  the  solution  used 
should  exert  its  full  effect  upon  the  cornea,  as  in  kera- 
titis or  iritis,  the  patient's  head  should  be  thrown  back 
and  he  should  be  directed  to  look  downward;  the  upper 
lid  being  then  drawn  up,  it  is  easy  to  cause  the  drop  to 
fall  directly  upon  the  exposed  cornea.  Under  other 
circumstances  it  is  more  convenient  to  apply  the  drop 
between  the  lower  lid  and  the  eyeball,  the  patient 
looking  upward  and  the  lid  being  drawn  slightly  away 
from  the  ball  (Fig.  8). 

Apothecaries  have  a  reprehensible  habit,  in  preparing 
solutions  for  the  eye,  of  using  a  mortar  and  pestle  to 
mix  the  ingredients  indicated.  This  is  wholly  un- 
necessary, and  nearly  always  results  in  contaminating 
the  solution,  as  is  shown  in  a  few  days  by  the  appearance 
in  it  of  a  fungous  growth.  It  is  a  practice  which  is 
without  excuse,  and  which  ought  unquestionably  to  be 
abandoned.     Equally  deserving  of  condemnation,  and 


44  PREVALENT    DISEASES    OF    THE     EYE. 

for  much  the  same  reason,  is  the  habit  common 
among  physicians  of  prescribing  rose-water,  instead 
of  distilled  water,  as  a  solvent  for  drugs  intended  for 
application  to  the  eye,  because  it  has,  or  is  supposed  to 
have,  a  pleasant  odor.  There  is  a  very  general  popular 
belief  that  collvria  in  order  to  be  efficacious  must  be 


Fig.  8. — Convenient  method  of  dropping  solutions  into  the  eye. 

"strong,"  must  cause  decided  smarting  when  applied 
to  the  eye.  It  is  scarcely  necessary  to  say  that  this 
belief  is  without  warrant. 

Such  agents  as  protargol,  strong  solutions  of  silver 
nitrate,  etc.,  which  are  commonlv  applied  to  the 
everted  lids,  can  be  applied  most  conveniently  by  mrans 


GENERAL    OBSERVATIONS     UPON    TREATMENT.  45 

of  a  mop  made  by  wrapping  a  little  absorbent  cotton 
around  the  sharp  end  of  a  wooden  toothpick.  Oint- 
ments may  be  applied  to  the  inner  surface  of  the  upper 
or  lower  lid,  the  eye  being  directed  downward  in  one 


Fig.  9. — .Applying  oialmeni  to  the  eye  wiih  a  wooden  toothpick. 

case  and  upward  in  the  other,  with  the  broad,  flat  end 
of  a  toothpick  (Fig.  9).  If  intended  for  application  to 
the  lids  only,  they  may  be  rubbed  on  with  the  finger-tip. 
In  preparing  ointments  for  application  to  the  eye 
vaselin   or  some    similar  preparation   should   be   used 


46  PREVALENT    DISEASES    OF    THE     EYE. 

as  a  base,  since  it  is  advantageous  that  they  should 
melt  at  the  temperature  of  the  body  and  so  become 
diffused  throughout  the  conjunctival  sac;  but  when 
intended  for  application  to  the  lids  this  is  a  disadvan- 
tage, and  a  firmer  base,  such  as  "vaselin  cerate"*  or 
cold-cream,  should  be  used. 

Of  all  local  remedies  employed  in  the  treatment  of 
eye  diseases,  atropin  is,  perhaps,  the  most  valuable. 
It  is  commonly  prescribed  in  aqueous  solution,  the 
sulphate  being  used  because  it  is  freely  soluble  in  water. 
Its  value  depends  not  only  upon  its  efficacy  in  relieving 
pain  and  photophobia  and  favorably  influencing  in- 
flammation of  various  structures  of  the  eye,  but  upon 
its  action  as  a  mydriatic,  its  mechanical  effect  in  en- 
larging the  pupil,  which,  as  is  w^ell  known,  is  of  ines- 
timable value  in  the  treatment  of  iritis.  It  is  prescribed 
in  solutions  varying  in  strength  from  one-eighth  of  a 
grain  to  eight  grains  to  the  ounce,  according  to  the 
effect  desired.  In  iritis,  and  in  other  non-glaucoma- 
tous  inflammations  attended  by  pain,  lacrimation  and 
photophobia,  a  solution  of  the  strength  of  four  grains 
to  the  ounce  (exceptionally,  an  eight-grain  solution) 
is  commonly  employed.  In  inflammations  in  which 
these  symptoms  are  not  so  marked,  as,  for  example, 
the  usual  type  of  phlyctenular  kerato-conjunctivitis, 
a  strength  of  one  grain  to  the  ounce  generally  suffices. 
The  very  weak  solutions,  the  quarter-grain-  or  eighth- 
grain-to-the-ounce  solutions,  are  used  chiefly  for  their 
mydriatic  effect,  the  former  being  applied  once  in  three 
or   four   days   to    produce    a    continuous    but  not  very 


*  Composed  of  yellow  wax,  one  part;  vaselin,  four  parts.  An  oint- 
ment suggested  by  the  author  some  years  since.  It  is  of  suitable 
consistence,  and  will  keep  for  a  very  long  time  without  becoming 
rancid. 


GENERAL    OBSERVATIONS    UPON    TREATMENT. 


47 


marked  mydriasis — to  improve  the  vision,  for  example, 
in  incipient  cataract  when  the  opacity  is  confined  to 
the  central  portion  of  the  lens;  the  latter,  as  a  sub- 
stitute for  the  more  evanescent  mydriatics,  when  a 
transient  dilatation  of  the  pupil  is  needed  to  facilitate 
inspection  of  the  lens  or  deeper  eye  structures. 

It  is  well  to  remember  that  the  mydriasis  produced 
by  a  strong  solution  of  atropin — a  four-grain  solution — 
will  frequentlv  not  disappear  entirely  for  fifteen  or  six- 
teen days.  It  is  inexcusable,  therefore,  to  use  such  a 
solution  when  only  a  transient  effect  upon  the  pupil 
is  desired.  Euphthalmin  is  the  most  evanescent  my- 
driatic that  we  possess,  its  effect  lasting  scarcely 
twenty-four  hours;  but  it  is  a  very  expensive  drug, 
and  must  be  used  in  quite  strong  soliitions — four  to 
five  per  cent. — to  insure  the  desired  result.  Homatro- 
pin  is  effective  in  much  weaker  solutions — two  to  four 
grains  to  the  ounce — and,  though  its  action  upon  the 
pupil  is  somewhat  more  prolonged,  it  is  a  very  satis- 
factory agent  to  employ  when  only  a  brief  mydriasis 
is  desired. 

Although,  as  has  just  been  said,  atropin  is  so  valu- 
able an  agent,  its  use  is  attended  with  certain  unfavor- 
able possibilities.  In  persons  advanced  in  life  it  some- 
times precipitates  an  attack  of  glaucoma.  Probably, 
this  happens  only  when  there  exists  a  predisposition  to 
this  disease;  but,  at  all  events,  it  has  led  to  caution  in 
its  use  in  old  persons  and  an  indisposition  to  prescribe 
it  under  such  circumstances  unless  the  need  for  it  is 
clear.  It  is,  doubtless,  by  dilating  the  pupil  and  crowd- 
ing the  iris  into  the  periphery  of  the  anterior  chamber, 
and  thus  clogging  the  lymph-passages  in  this  region, 
that  this  unfortunate  result  is  brought  about.  In 
penetrating   wounds    near   the    border   of  the    cornea. 


48  PREVALENT    DISEASES    OF    THE     EYE. 

and  in  ulcers  in  this  region  which  have  perforated,  or  are 
about  to  perforate,  into  the  anterior  chamber,  its  em- 
ployment is  contraindicated,  since  through  its  paralyz- 
ing effect  upon  the  sphincter  pupilhe  it  favors  the  occur- 
rence of  hernia  of  the  iris. 

Again,  the  prolonged  use  of  atropin  mav  cause  a  con- 
junctivitis of  follicular  type,  which  is  usuallv  accompa- 
nied by  annoying  itching,  and  in  persons  peculiarly 
susceptible  to  the  action  of  belladonna  even  a  single 
application  of  an  atropm  solution  to  the  eye  may  produce 
a  conjunctivitis  of  this  character,  accompanied  at  times 
by  marked  edema  and  redness  of  the  lids  and  face. 
Occasionally,  too,  when  used  in  old  persons,  especially 
when  both  eyes  are  closed,  as  after  operations  for 
cataract,  it  causes  delirium,  which  under  such  circum- 
stances may  have  serious  consequences.  Anv  one  of 
the  commonly  employed  mydriatics,  it  should  be  said, 
may  produce  the  same  unpleasant  consequences  as 
atropin,  and  the  contraindications  to  their  use  are  the 
same.  Homatropin  is  the  least  poisonous,  and,  there- 
fore, is  the  least  likely  to  cause  delirium.  A  peculiar 
susceptibilitv  to  atropin,  such  as  has  been  described, 
does  not  necessarily  imply  a  like  susceptibility  to  all 
the  other  mydriatics;  so  that  when  it  is  encountered 
some  other  member  of  the  group — such  as  hyoscvamin, 
scopolamin,  or  duboisin — may,  not  infrequently,  be 
substituted  with  good  effect. 

As  mydriatics  tend  to  induce  glaucoma  by  dilating 
the  pupil  and  obstructing  the  filtration  angle  at  the 
periphery  of  the  anterior  chamber,  mvotics  (eserin 
and  pilocarpin)  tend  to  reduce  increased  intraocular 
tension,  to  control  glaucoma,  by  contracting  the  pupil 
(which  under  such  circumstances  is  almost  always 
abnormally  dilated),  drawing  the  iris  toward  the  center 


GENERAL    OBSERVATIONS    UPON    TREATMENT.  49 

of  the  anterior  chamber  and  freeing  the  lymph-spaces 
at  its  periphery.  Such  being  the  case,  it  is  evident 
that  we  have  in  the  behavior  of  the  pupil  a  guide  to 
the  strength  of  the  myotic  solution  required  in  the 
treatment  of  glaucoma.  The  stronger  solutions  of 
eserin,  a  much  more  energetic  myotic  than  pilocarpin, 
through  the  vigorous  contraction  of  the  sphincter 
pupillae  and  the  ciliary  muscle  which  they  induce, 
often  cause  pain  in  the  eye,  and  when  their  use  is 
long  continued  may  even  excite  iritis.  It  is  desira- 
ble, therefore,  that  they  should  not  be  used  except 
when  clearly  demanded.  In  a  word,  the  weak- 
est solution  of  eserm  which  will  cause  the  pupil  to 
contract,  and  will  maintain  it  in  a  state  of  contraction 
(not  excessive),  is  what  one  should  aim  to  employ  in 
endeavoring  to  control  increased  intraocular  tension. 
In  an  acute  attack  of  inflammatory  glaucoma  it  often 
happens  that  even  the  strongest  solution  of  eserin  that 
we  are  in  the  habit  of  using  (four  grains  to  the  ounce) 
will  fail  to  overcome  the  dilatation  of  the  pupil;  but, 
on  the  other  hand,  in  the  intervals  between  the  attacks, 
when  it  IS  used  as  a  prophylactic,  and  in  glaucoma 
simplex  a  strength  of  a  quarter  of  a  grain,  or  even  an 
eighth  ot  a  grain,  to  the  ounce  usually  suffices  to  ac- 
complish the  desired  result.  In  inflammatory  glau- 
coma iridectomy,  of  course,  is  the  sovereign  remedy, 
and  resort  to  it  should  not  be  unnecessarily  delayed; 
but,  if  during  an  acute  exacerbation  eserin  is  to  be  used, 
a  strong  solution  (four  grains  to  the  ounce)  should 
be  prescribed  at  once,  without  waiting  to  ascertain 
whether  a  weaker  solution  will  cause  the  pupil  to 
contract.  When,  however,  the  conditions  are  not 
urgent,  one  should  determine  by  trial  the  weakest  solu- 
tion of  eserin  that  will  maintain  the  pupil  in  a  state  of 
4 


50  PREVALENT    DISEASES    OF    THE     EYE. 

moderate  contraction  when  applied  twice  or,  at  most, 
three  times  a  day,  and  direct  this  for  future  use. 

The  prolonged  use  of  a  collyrium  of  eserin,  which  is 
commonly  prescribed  in  the  form  of  the  sulphate,  occa- 
sionally excites  a  follicular  conjunctivitis  very  similar 
to  that  sometimes  induced  by  atropin.  When  this 
happens,  or  when  for  any  reason  eserin  is  not  well 
borne,  the  hydrochlorate  of  pilocarpin  should  be  sub- 
stituted, and  since  its  myotic  action,  as  has  been 
said,  is  much  less  powerful  than  that  of  eserin,  it  must 
be  prescribed  in  considerably  stronger  solutions — in 
solutions  of  from  one  to  eight  grains  to  the  ounce. 
The  myotics,  eserin  especially,  are  distinctly  contra- 
indicated  in  iritis,  and  if  used  through  misapprehension 
of  the  true  condition  are  sure  to  do  harm,  increasing 
the  pain  and  aggravating  the  inflammation. 

Astringents  and  antiseptic  agents,  as  has  been 
pointed  out,  are  especially  indicated  in  the  treatment 
of  inflammations  of  the  conjunctiva.  In  the  milder 
types  of  conjunctivitis,  such  as  the  catarrhal  and 
follicular  varieties,  they  should  be  used  in  compara- 
tively weak  solutions.  Zinc  sulphate,  on  the  whole, 
is  the  most  useful  astringent,  and  boracic  acid  and 
bichlorid  of  mercury  are  the  most  useful  antiseptics, 
in  these  conditions.  The  collyrium  which  I  have 
found  especially  efficacious  in  catarrhal  conjunctivitis 
is  one  containing  half  a  grain  of  sulphate  of  zinc  and 
ten  to  twelve  grains  of  boracic  acid  to  the  ounce. 
Dropped  into  the  eye  freely,  three  times  a  day,  it  will 
seldom  fail  to  cure  an  acute  attack  in  a  very  few  days. 
Bichlorid  of  mercur)',  which  is  useful  more  particularly 
in  follicular  conjunctivitis,  in  \ernal  catarrh,  and  in 
blennorrhea  of  the  lacrimal  passages,  should  be  pre- 
scribed in  solutions  varying  in  strength  from  i  :  12,000 


GENERAL    OBSERVATIONS     UPON    TREATMENT.  5I 

to  I  :  8000.  The  addition  of  sodium  chlorid  to 
the  solution,  in  the  proportion  of  three  grains  to  the 
ounce  (about  the  strength  of  normal  salt  solution), 
seems  to  add  to  its  efficacy,  and,  moreover,  renders 
it  more  acceptable  to  the  eye.  In  asthenopia,  in  hyper- 
emia of  the  conjunctiva,  in  mild  cases  of  catarrhal 
conjunctivitis,  and,  agam,  when  one  is  uncertain  as 
to  the  diagnosis,  and  wishes  to  prescribe  something 
that  will  do  a  measure  of  good,  at  least,  and  will  surely 
do  no  harm,  boracic  acid  (lo  to  12  grains  to  the  ounce) 
is  especially  to  be  commended.  In  addition  to  its  slight 
antiseptic  and  astringent  action,  it  is  decidedly  soothing 
and  grateful  to  irritable  eyes. 

In  the  severer  types  of  conjunctivitis,  in  purulent 
(gonorrheal)  and  trachomatous  conjunctivitis,  more 
energetic  treatment  is  demanded,  much  stronger 
astringent  and  antiseptic  solutions  are  called  for,  and 
in  the  first-named  affection,  especially,  very  much 
more  assiduous  attention.  Silver  nitrate  in  2  per  cent, 
solution  or,  preferably,  protargol  or  argyrol  in  20  to  40 
per  cent,  solution  must  here  be  employed. 

In  applying  tincture  of  iodin  or  pure  carbolic  acid 
to  corneal  ulcers,  the  application  may  be  conveniently 
made  by  means  of  a  sharply  pointed  wooden  toothpick, 
about  the  tip  of  which  a  very  little  absorbent  cotton 
— a  few  fibers  only — has  been  wound.  To  prevent 
the  cornea  being  acted  upon  more  extensively  than 
is  desired  the  improvised  applicator  should  carry  only 
a  very  small  quantity  of  the  fluid. 

Cocain  may  be  used  with  good  effect  to  do  away 
with  the  pain  caused  by  the  application  to  the  eye  of 
such  severe  remedies  as  silver  nitrate,  copper  sulphate, 
carbolic  acid,  iodin,  etc.;  but  as  a  remedial  agent  per 
se,  apart  from  its  use  as  a  local  anesthetic,  it  should 


52  PREVALENT    DISEASES    OF    THE     EYE. 

never,  in  my  judgment,  be  employed.  For  not 
only  is  the  relief  which  it  affords — from  pain,  pho- 
tophobia, etc. — very  evanescent,  but  it  markedly  dis- 
turbs the  nutrition  of  the  cornea,  causes,  not  infre- 
quently, desquamation  of  the  corneal  epithelium,  and 
brings  about  a  condition  peculiarly  favorable  to  the 
invasion  of  pathogenic  bacteria.  From  time  to  time 
cases  of  inflammation  of  the  superficial  structures  of 
the  eye  have  come  under  my  observation  in  which 
cocain  had  been  used,  and  in  which  its  ill  effects  were 
plainly  manifest. 

Dionin,  one  of  the  more  recent  additions  to  the 
pharmacopoeia  of  the  ophthalmologist,  owes  its  value 
to  its  action  as  an  analgesic  and  a  lymphagogue.  It  is 
useful  in  iritis,  not  only  because  of  its  analgesic  effect, 
but  because  it  increases  the  mydriatic  action  of  the 
atropin,  in  association  with  which  it  is  employed. 
In  inflammatory  glaucoma  it  tends  to  reduce  the 
intraocular  tension,  as  well  as  to  relieve  pain.  It  is 
beneficial  also  in  keratitis,  more  especially  in  paren- 
chymatous keratitis,  and  through  its  action  as  a  lymph- 
agogue it  promotes  the  absorption  of  recent  corneal 
opacities  and  the  remnants  of  cortical  lens  substance 
left  after  operations  for  cataract.  It  is  used  commonly 
in  five  per  cent,  solution,  and  in  this  strength  may  be 
applied  to  the  eye  twice  to  four  times  daily.  The 
immediate  effect  of  its  application  is  to  cause  con- 
siderable irritation,  not  infrequently  decided  pain, 
and  pronounced  edema  and  congestion  of  the  conjunc- 
tiva. The  analgesia  which  supervenes  in  fifteen  or 
twenty  minutes  lasts  for  some  hours.  A  tolerance  to 
dionin  is  established  usually  after  it  has  been  used  a  few 
days,  and  after  this  its  further  employment  is  of  doubt- 
ful ^  alue. 


GENERAL    OBSERVATIONS    UPON    TREATMENT.        53 

The  use  of  opium  as  a  local  application  in  eye  dis- 
eases, formerly  much  in  vogue,  does  not  receive  at  the 
present  day  the  attention  it  deserves.  I  am  not  in- 
clined to  employ  it  as  a  collyrium — for  application  to 
the  eye  itself;  but,  as  a  lotion  to  he  applied  by  means 
of  a  gauze  or  linen  pad  to  the  closed  lids,  I  have  found 
it  a  most  useful  remedy  in  all  painful  inflammations 
of  the  eye,  and  especially  in  those  of  traumatic  origin. 
It  should  be  prescribed  in  the  strength  of  from  ten  to 
fifteen  grains  of  the  extract  of  opium  to  four  ounces 
of  distilled  water,  to  which  it  is  often  advantageous 
to  add  from  forty  to  sixty  grains  of  boracic  acid.  When 
its  action  is  favorable,  it  can  hardly  be  applied  too 
persistently,  though  it  is  well  to  remember  that  in  sus- 
ceptible individuals  opium  used  in  this  way  occasion- 
ally produces  its  characteristic  constitutional  eff'ect. 
As  a  rule,  it  should  be  applied  at  the  temperature  of 
the  atmosphere,  but  occasionally  it  affords  greater 
relief  when  used  as  hot  as  can  be  conveniently  borne. 
A  gauze  pad  of  suitable  thickness,  wet  with  a  saturated 
solution  of  boracic  acid  or  with  the  lotion  of  opium 
and  boracic  acid  just  mentioned,  and  covered  with  a 
piece  of  rubber  protective  or  oiled  silk  or  muslin,  makes 
an  excellent  "poultice,"  and  one  which  is  much  more 
cleanly  and  convenient  of  application  than  the  poultices 
of  flaxseed-meal,  etc.,  which  are  commonly  employed. 

Ointments  are  applied  to  the  lids  to  prevent  their 
becoming  stuck  together  bv  the  drying  of  discharge 
upon  the  eyelashes,  as  in  the  different  types  of  conjunc- 
tivitis, and  to  cure  inflammation  of  the  lids  or  their 
margins  (blepharitis  marginalis).  For  the  purpose 
first  named  a  simple,  bland  ointment,  such  as  cold- 
cream,  to  which  boracic  acid  may  be  added  (five 
grains  to  the  dram),  is  best  adapted.     For  blepharitis 


54  PREVALENT    DISEASES    OF    THE     EYE. 

marginalis  nothing  is  so  generally  efficacious  as  the 
so-called  "yellow  salve"  (yellow  oxid  of  mercury,  2 
grains;  cold-cream  or  "vaselin  cerate,"  i  dram). 
An  ointment  of  salicylic  acid  of  the  same  strength  is 
also  useful  in  this  condition,  as  well  as  in  eczema 
involving  the  lids  or  neighboring  parts. 

In  burns  of  the  eye,  whether  from  hot  substances 
or  caustic  agents,  and  in  abrasions  of  the  cornea,  castor 
oil  is  a  useful  application,  affording,  as  it  does,  a  pro- 
tective covering  to  the  inflamed  surfaces.  A  still  more 
soothing  application  under  such  circumstances  is  a 
solution  of  atropin  (the  alkaloid,  not  the  sulphate) 
in  castor  oil  (four  to  eight  grains  to  the  ounce). 

Light,  in  so  far  as  its  influence  upon  eyes  which  are 
the  seat  of  pathological  changes  is  concerned,  is  not 
the  reprehensible  thing  it  was  once  supposed  to  be, 
and  the  confinement  of  patients  with  ocular  inflamma- 
tions in  quite  dark  rooms,  as  well  as  the  closure  of 
the  eyes  by  thick  bandages  designed  to  exclude  light, 
very  generally  practised  in  former  days,  is  now  regarded 
not  only  as  uncalled  for  but  as  actually  harmful  in 
many  conditions.  The  misadventures,  especially  those 
occurring  after  important  operations  upon  the  eye, 
formerly  attributed  to  premature  or  undue  exposure 
of  the  eyes  to  light,  are  now  known  to  be  caused — in 
the  great  majority  of  instances,  at  all  events — by  bac- 
terial infection,  against  which,  at  the  present  day,  we 
guard  with  greater  assiduity  than  we  display  in  trying  to 
avoid  the  supposed  ill  eff'ects  of  light. 

In  saying  this,  however,  I  do  not  wish  to  be  under- 
stood as  holding  that  inflamed  and  painful  eyes  should 
not  be  protected  from  undue  exposure  to  light;  for, 
as  a  rule,  it  is  desirable,  unquestionably,  that  they 
should  be.     An  eye  in  which  there  exists  inflammation 


GENERAL    OBSERVATIONS    UPON    TREATMENT. 


55 


of  the  iris,  of  the  cihary  body,  or  the  cornea,  or  which 
is  the  seat  of  an  attack  of  acute  glaucoma,  will  cer- 
tainly be  made  more  photophobic  and  painful  and, 
perhaps,  actually  worse,  so  far  as  the  inflammatory 
condition  is  concerned,  by  undue  exposure  to  light, 
and  this  should,  without  doubt,  be  avoided;  but  this 
does  not  mean  that  the  patient  must  be  shut  up  in 
an   absolutely   dark   room,   or  that   his   eyes   must   be 


Fig.   lo. — Author's  bandage,  as  applied  to  one   eye. 

confined  by,  and  subjected  to  the  poultice-like  action 
of,  a  roller  bandage  of  many  thicknesses.  It  means 
simply  that  he  should  avoid  very  light  rooms,  and  that 
he  should  w^ear  smoke-tinted  (but  not  too  darkly 
tinted)  spectacles  (coquilles),  which  may  be  supple- 
mented by  a  monocular  or  a  binocular  eye-shade  or 
a  piece  of  black  court-plaster  attached  to  the  glass 
which  covers  the  afi^ected  eye,  if  photophobia  be  a 
marked  symptom  of  the  attack. 


56 


PRFVALF.NT    DISEASES    OF    THE     EYE. 


Bandages  are  seldom  necessary  except  after  certain 
operations,  or  after  serious  injuries  of  the  eye,  or  for 
the  purpose  of  holding  in  position  pads  used  tor  the 
application  of  lotions  to  the  lids;  and  for  these  pur- 
poses a  light,  easily  applied  and  easily  removed  bandage, 
such  as  that  contrived  Some  years  ago  by  the  author* 
(Figs.  10  and  1 1),  is  greatly  to  be  preferred  to  the  clumsy 


"icy  r 

Fig.   II. — Author's  bandage,  as  applied  to  both  eyes. 

*  This  bandage,  which  can  be  used  for  one  or  for  both  eves, 
as  shown  in  the  illustrations,  consists  of  a  head-piece,  to  which 
the  tapes  are  attached,  and  an  eye-piece  with  a  buttonhole  at 
each  end,  through  which  the  tapes  are  passed.  The  head-piece 
consists  of  two  straight  strips  of  cotton  cloth,  of  good  quality, 
twelve  inches  long  and  one  inch  and  three-quarters  wide,  the 
ends  of  which  are  sewed  together  so  that  the  strips  shall  form 
a  right  angle.  The  eye-piece,  made  of  the  same  material  cut  bias, 
when  intended  for  one  eye,  is  of  oval  shape,  six  inches  and  a  half 
long  by  two  inches  and  three-quarters  wide  at  its  widest  part;  when 
mtended  for  closing  both  eyes,  it  is  rectangular,  and  should  be 
seven  inches  and  a  half  in  length  by  two  inches  and  three-quarters 
m  width.  The  size  of  the  head-piece  may  be  varied,  to  fit  small 
or  large  heads,  by  cutting  the  strips  a  half-inch  shorter  or  longer. 


GENERAL    OBSERVATIONS    UPON    TREATMENT.        57 

roller  bandage;  which,  however,  many  ophthalmic  sur- 
geons employ  even  at  the  present  day. 

It  is  hardly  necessary  to  say  that  inflamed  and 
painful  eyes  should  be  given  complete  rest  from  such 
work  as  reading,  writing,  sewing,  and  the  like;  but  it 
may  be  well  to  point  out  that  this  is  as  true  when  only 
one  eye  is  affected  as  it  is  when  both  are  involved, 
since  it  is  almost  as  trying  to  the  inflamed  eye  to  have 
Its  fellow  taxed  as  it  is  to  be  taxed  itself. 

It  is  often  extremely  difficult  to  examine,  or  to  make 
applications  to,  the  eyes  of  unruly  children.  When 
this  difficulty  is  met  with,  it  may  be  easily  overcome 
in  the  followmg  manner:  Let  the  child  be  placed  across 
the  lap  of  an  attendant  or  nurse,  who  is  instructed  to 
hold  its  hands  firmly.  Then  let  the  physician,  seating 
himself  in  a  convenient  position  for  the  purpose,  and 
having  thrown  a  towel  over  his  lap,  take  the  child's 
head  between  his  knees.  In  this  way  he  is  enabled  to 
hold  it  very  securely,  while,  both  his  hands  being  free, 
it  is  not  difficult  for  him  to  separate  the  lids  in  order 
to  inspect  the  eye,  or  to  make  such  applications  as 
may  be  needed. 

Constitutional  Remedies. — As  is  indicated  by  the 
briefness  of  the  list  given  in  the  early  part  of  this 
chapter,  the  number  of  constitutional  remedies  required 
in  the  treatment  of  diseases  of  the  eye  is  small. 

Since  syphilis  plays  a  very  important  role  in  the  eti- 
ology of  eye  diseases,  the  antisyphilitic  drugs — mercury 
and  potassium  iodid — are  among  the  most  useful 
remedial  agents  employed  in  ophthalmic  practice;  but 
their  value,  it  should  be  said,  is  not  limited  to  diseases 
of  syphilitic  origin  only.  On  the  contrary,  they  are 
of  2;reat  value  in  all  ocular  inflammations  in  which 
there  is  a  tendency  to  plastic  exudation  and  proliferation 


58  PREVALENT    DISEASES    OF    THE     EYE. 

of  connective  tissue.  This  is  especially  true  of  inflam- 
mations of  the  uveal  coat  (iris,  ciliary  body,  and  cho- 
roid), of  the  retina  and  optic  nerve,  and  of  the  motor 
nerves  which  supply  the  extrinsic  eye  muscles.  On 
the  other  hand,  a  tendency  to  purulent  infiltration, 
to  ulceration  and  necrosis,  especially  of  the  cornea, 
is  a  distinct  contraindication  to  their  use. 

When  it  is  important  to  bring  the  system  promptly 
under  the  influence  of  mercury,  as  in  syphilitic  iritis 
or  irido-choroiditis  of  severe  type,  we  can  not  do  better 
than  to  administer  calomel  in  small,  frequently  re- 
peated doses, — half  a  grain  every  hour  or  every  two 
hours, — guarded,  if  need  be,  by  small  doses  of  opium. 
Inunctions  of  mercurial  ointment  may  supplement 
the  calomel,  li  thought  desirable.  When  the  purpose 
of  the  inunctions  is  to  impress  the  system,  they  should 
be  made,  in  the  usual  way,  to  the  inside  of  the  thighs 
and  arms.  With  less  effect  upon  the  system,  a  decided 
impression  may  be  made  upon  the  eyes  by  applying 
mercurial  ointment  several  times  daily  to  the  forehead 
and  temples.  In  iritis  and  cyclitis  the  addition  of  ex- 
tract of  belladonna  to  the  mercurial  ointment,  in  the 
proportion  of  one  dram  to  the  ounce,  renders  this 
procedure  still  more  eflficacious. 

When  less  urgency  is  demanded,  one  of  the  best 
ways  of  administering  mercury  in  diseases  of  the  eye 
is  in  the  form  of  the  biniodid,  which  may  be  given  in 
solution  (with  the  addition  of  a  few  grains  of  potas- 
sium iodid)  or  in  tablet-triturates,  and  in  doses  varying 
from  a  sixteenth  to  a  thirty-second  of  a  grain,  three 
times  a  day.  When  the  exhibition  of  iron  as  well  as 
of  mercury  is  indicated,  as  is  frequently  the  case  in 
ocular  affections  dependent  upon  inherited  svphilis, 
the  syrup  of  the  iodid  of  iron  may  be  added,  in  such 


GENERAL    OBSERVATIONS    UPON    TREATMENT.         59 

proportion  as  desired,  to  the  biniodid  solution,  or,  if 
the  iodids  are  not  well  borne,  the  bichlorid  of  mercury 
in  solution,  with  the  addition  of  the  tincture  of  chlorid 
of  iron,  may  be  given  instead. 

Potassium  iodid,  in  order  to  secure  the  best  results 
in  the  ocular  maladies  in  which  it  is  indicated,  must 
often  be  given  in  liberal  doses.  This  is  especially  true 
of  the  diseases  of  the  eye  occurring  in  the  tertiary 
stage  of  syphilis,  of  the  disturbances  of  sight,  whether 
strictly  visual  or  motor,  arising  from  intracranial  af- 
fections, of  the  so-called  neuropathic  inflammations 
of  the  eye,  and  of  that  obscure  and  frequently  intractable 
disease,  serous  iritis,  or,  as  it  is  more  correctly  de- 
nominated, general  uveitis.  When  it  is  to  be  admin- 
istered in  increasing  doses,  it  is  convenient  to  prescribe 
it  in  saturated  solution,  so  that  each  drop  shall  repre- 
sent a  grain  of  the  iodid.  It  is  frequently  given,  with 
good  eff^ect,  in  combination  with  the  biniodid  or  bi- 
chlorid of  mercury. 

The  salicylates,  sodium  and  lithium,  are  remedies 
of  much  value,  not  only  in  rheumatic  affections  of  the 
eye  (which  comprise  a  not  insignificant  group),  but 
also  in  traumatic  and  post-operative  inflammations, 
and  even  in  iritis  and  iridocyclitis  of  syphilitic  origin. 
The  lithium  salt  is  supposed  to  have  a  somewhat  less 
disturbing  efi^ect  upon  the  stomach.  The  dose  of  each 
is  the  same — ten  to  twenty  grains  every  three  hours. 

,  When  they — and  this  is  true  also  of  potassium  iodid — 
are  not  well  borne  by  the  stomach,  two  teaspoonfuls  of 

i  Fairchild's  essence  of  pepsin  given  with  each  dose  will 

'  often  obviate  completely  this  difficulty. 

In  suppuration,  ulceration  and  necrosis  of  the 
cornea — the  conditions  which,  as  has  been  said,  espe- 
cially   contraindicate    the    administration    of   mercury 


60  PREVALENT    DISEASES    OF    THE     EYE. 

and  to  a  less  degree  that  of  potassium  iodid — quinin 
is  of  undoubted  value,  and  should  be  given  in  such 
doses  as  to  produce  cinchonism.  It  is  also  extremely 
useful,  especially  in  combination  with  iron  and  strych- 
nin or  nux  vomica,  in  those  affections  of  the  eye 
which  are  dependent  upon  an  impaired  state  of  the 
general  health,  such  as  phlyctenular  conjunctivitis  or 
keratitis,  blepharitis  marginalis,  eczema  of  the  lids, 
etc.  A  favorite  combmation  with  me  in  such  cases 
is  the  elixir  of  the  phosphates  of  iron,  quinin,  and 
strychnin,  preference  being  given  to  the  elixir  prepared 
by  Wyeth  and  Bro.,  since  it  contains,  besides  a  sixtieth 
of  a  grain  of  strvxhnin,  two  grains  of  iron  and  one 
grain  of  quinin  to  the  dram — more  than  twice  as  much 
of  the  two  last-named  ingredients  as  do  many  of  the 
preparations  which  are  called  by  the  same  name.  The 
syrup  of  the  iodid  of  iron,  which  is  more  often  admin- 
istered in  these  affections,  is  useful  when  they  are 
associated  with  a  distinctly  strumous  diathesis,  mani- 
fested by  enlarged  lymphatic  glands,  etc.;  but,  except 
under  such  circumstances,  the  iron,  quinin,  and  strych- 
nin combination  just  mentioned  has  afforded  me  de- 
cidedly better  results,  and  I  have  no  hesitation  in 
strongly  commending  it. 

Strychnin,  in  gradually  increasing  doses,  given  by 
the  mouth  and  not,  as  some  (absurdly,  I  think)  recom- 
mend, by  hypodermic  injection,  and  usually  in  con- 
nection with  potassium  iodid,  is  valuable  in  ambly- 
opic affections,  and  in  paralyses  of  the  ocular  muscles 
of  not  too  long  standing.  Opium  and  morphin  are 
chiefly  useful  for  the  relief  of  pain,  in  such  diseases  as 
iritis,  cyclitis,  and  inflammatory  glaucoma.  Sulphonal 
and  trional  I  have  found  especially  useful  in  giving 
quiet  sleep  and  relief  from  nervousness  after  important 


GENERAL    OBSERVATIONS    UPON    TREATMENT.        6l 

operations  upon  the  eye,  and,  as  a  matter  of  routine, 
I  prescribe  one  or  the  other  of  these  drugs,  to  be  given 
several  hours  before  bedtime,  after  cataract  extractions, 
iridectomies,  etc. 

There  can  be  no  question  as  to  the  value  of  an 
energetic  cathartic,  particularly  one  containing  a  liberal 
proportion  of  calomel,  in  many  inflammatory  aflfections 
of  the  eye,  and  especially  in  iritis,  in  acute  glaucoma, 
and  in .  phlyctenular  kerato-conjunctivitis,  accompa- 
nied, as  it  so  often  is,  by  eczema  of  the  lids  and  face 
and  by  nasal  catarrh.  In  the  last-named  condition 
the  good  which  it  accomplishes  so  promptly  seems, 
in  great  measure,  to  be  due  to  its  action  in  ridding 
the  alimentary  canal  of  bacteria  and  their  toxins,  or, 
as  the  older  writers  used  to  express  it,  in  "Cleaning 
out  the  prunes  vice.'' 

Pilocarpin,  which,  like  strychnin,  may  be  given 
by  the  mouth  with  good  effect  and  without  incon- 
venience, and  which,  therefore,  should  not  be  admin- 
istered hypodermically,  is  useful  at  times  in  retinitis, 
in  choroiditis,  and  in  detachment  of  the  retina.  Col- 
chicum  and  lithium  (lithia  water  or  the  citrate  or 
carbonate  of  lithium  tablets)  are  indicated  in  gouty 
inflammations  of  the  eye  (iritis,  retinitis,  scleritis,  and 
chronic  conjunctivitis),  and  arsenic,  generally  in  the 
form  of  Fowler's  solution,  in  the  different  varieties 
of  herpes. 

The  diphtheria  antitoxin,  as  reported  by  trust- 
worthy observers,  has  proved  so  emmently  eflftcacious 
in  controlling  diphtheritic  conjunctivitis — a  disease 
hitherto  regarded  as  one  of  the  most  dangerous  to 
which  the  eye  is  liable — as  to  have  completely  over- 
shadowed all  local  measures.  It  should  be  adminis- 
tered as  in  diphtheria  affecting  the  fauces. 


62  PREVALENT    DISEASES    OF    THE     EYE. 

In  acute  suppurative  processes  involving  the  lids, 
the  lacrimal  sac,  or  the  orbit,  sodium  pyrophosphate, 
in  liberal  doses,  is  of  undoubted  value.  For  an  adult 
the  dose  is  twenty  grains  every  tw^o  hours;  for  a  child, 
from  ten  to  fifteen  grains  every  two  or  three  hours.  It 
should  be  prescribed  in  solution,  and,  as  it  is  not 
very  soluble,  as  much  as  half  an  ounce  of  water  should 
be  allowed  for  each  twenty  grains  of  the  salt. 


CHAPTER  III. 
DISEASES  OF  THE  EYELIDS  AND  ORBIT. 

DISEASES  OF  THE  EYELIDS. 

Diseases  of  the  eyelids  are  of  common  occurrence 
and,  as  a  rule,  may  be  dealt  with  satisfactorily  by  the 
general  practitioner.  Usually,  they  require  local  treat- 
ment only,  but  this  is  not  always  the  case. 

Blepharitis  Marginalis. — Inflammation  of  the  lid- 


Fig.   12. — Blepharitis  marginalis  (Haab). 

margin,  or  blepharitis  marginalis  (Fig.  12),  a  condition 
not  infrequently  met  with  in  both  children  and  adults, 
is  characterized  by  redness  of  the  edges  of  the  lids, 
the  formation  of  crusts  upon  them,  and,  in  severe  and 
protracted  cases,  by  more  or  less  complete  loss  of  the 
eyelashes.  Because  the  inflammation  is  not  limited 
to  the  surface  of  the  lid,  but  involves  as  well  the  hair- 
follicles  and  accompanying  sebaceous  glands,  it  is  some- 
times called  blepharo-adenitis.     In  severe  cases  ulcera- 

6^ 


64 


PREVALENT    DISEASES    OF    THE    EYE. 


tion  occurs  about  the  orifices  of  the  follicles  (Fig.  13); 
it  is  usually  superficial,  however,  and  the  loss  of  tissue 
is  slight.  It  is  commonly  a  chronic  condition,  and, 
unless  its  etiology  is  understood  and  the  treatment 
regulated  with  reference  thereto,  it  is  apt  to  be  an 
intractable  one.  In  children,  it  is  usually  due  to  mal- 
nutrition and  a  consequent  depraved  state  of  the  sys- 
tem, and  under  such  circumstances  it  is  often  accom- 
panied by  eczema  of  the  face  or  ears  or  by  phlyctenular 
conjunctivitis.     In  adults,  it  arises  exceptionally,  espe- 


Fig.  13. — The  palpebral  aperture;  the  lid  margin  somewhat  everted,  so 
as  to  show  the  openings  of  the  ducts  of  the  meibomian  glands,  d,  e,  the  fol- 
licles of  the  cilia  (the  lashes  having  been  removed),  b,  c,  and  the  lacrimal 
pun  eta,  /,  g  (Nunneley). 


cially  in  strumous  subjects,  from  a  like  cause;  but 
much  more  frequently  it  is  produced  by  accommodative 
strain,  that  is  to  say,  is  dependent  upon  an  error  of 
refraction,  such,  for  example,  as  hypermetropia  or 
astigmatism.  The  severe  cases,  attended  by  ulceration, 
destruction  of  the  hair-follicles,  and  permanent  loss 
of  the  eyelashes,  are  seldom  met  with  except  in  the 
strumous  variety  of  the  disease.  Those  cases  which 
have  their  origin  in  accommodative  strain,  though 
prone  to  chronicity,  are  not  of  this  severe  type. 


DISEASES    OF    THE    EYELIDS    AND    ORBIT.  65 

Exceptionally,  blepharitis  marginalis  is  dependent 
upon  lacrimal  disease — when  it  is  apt  to  be  unilateral — 
or  upon  chronic  rhinitis.  It  occurs  also  in  connection 
with  acne  rosacea,  but  then  the  inflammation  usually 
is  not  confined  to  the  lid-margin. 

Treatment. — The  treatment  of  blepharitis  marginalis, 
when  regard  is  had  to  the  underlying  cause  which  has 
given  rise  to  it,  generally  yields  most  gratifying  results; 
on  the  other  hand,  if  this  is  not  taken  into  account,  the 
outcome  is  likely  to  be  far  from  satisfactory.  Speaking 
broadly,  it  may  be  said  that  when  a  case  of  chronic 
blepharitis  marginalis  is  encountered  in  an  adult  or 
in  a  child  old  enough  to  attend  school,  without  other 
signs  of  constitutional  disorder,  the  presumption  is 
warranted  that  an  error  of  refraction,  or  possibly  an 
anomaly  of  the  ocular  muscles,  exists,  and  it  may  be 
added  that  the  cure  of  the  lid  affection  will  necessarily 
involve  the  adjustment  of  suitable  glasses.  On  the 
other  hand,  when  the  disease  is  met  with  in  young 
children,  especially  in  association  w^ith  facial  eczema  or 
phlyctenular  conjunctivitis,  remedial  measures  having 
reference  to  the  disordered  state  of  the  system  are  of 
the  first  importance,  and  this  is  true  also  of  those  cases 
which  occur  in  strumous  adults. 

The  most  useful  local  remedy  in  all  varieties  of 
blepharitis  is  the  yellow  oxid  of  mercury.  It  should 
be  used  in  the  form  of  an  ointment,  of  the  strength 
of  two  grains  to  the  dram  (hydrarg.  ox.  flav.,  gr.  viij; 
ung.  aquae  rosae  vel  "vaselin  cerat.,"  5ss).  A  single 
application  in  twenty-four  hours  usually  suffices,  the 
best  time  for  this  being  just  before  going  to  bed. 
Before  each  application  the  margins  of  the  lids  should 
be  carefully  freed  of  all  crusts  by  persistent  bathing 
with  warm  water,  a  bit  of  soft  sponge  or  rag  being 
5 


66  PREVALENT    DISEASES    OF    THE     EYE. 

used  to  facilitate  the  detachment  of  the  scabs,  and  all 
loose  eyelashes  should  be  removed  by  gentle  traction 
v^ith  the  thumb  and  finger.  The  efficacy  of  the  treat- 
ment depends,  in  no  small  degree,  upon  the  thorough- 
ness with  which  this  preliminary  cleansing  is  done. 
In  the  rare  instances  in  which  the  "yellow  oxid"  oint- 
ment does  not  act  favorably,  one  may  employ  instead, 
and  in  the  same  manner,  an  ointment  of  salicylic 
acid  (gr.  j-ij  to  5j). 

In  obstinate  cases,  and  especially  in  those  of  severe 
type,  attended  by  ulceration,  much  benefit  results 
from  touching  lightly  the  margins  of  the  lids  (previ- 
ously freed  of  crusts)  with  a  pointed  crayon  of  silver 
nitrate.  In  doing  this  care  should  be  exercised  to 
prevent  the  silver  salt  from  coming  in  contact  with 
the  conjunctival  surface  of  the  lid,  otherwise  consider- 
able irritation  of  the  eye  will  result. 

When  the  blepharitis  is  dependent  upon  a  disordered 
state  of  the  system,  and  especially  when  it  is  accom- 
panied by  eczema  of  the  face,  phlyctenular  conjunc- 
tivitis or  otorrhea,  as  a  step  preliminary  to  the  tonic 
treatment  which  is  indicated,  the  bowels  should 
be  moved  freely  by  one  or  more  doses  of  calomel, 
scammony,  and  rhubarb,  an  excellent  purgative  com- 
bination, which  will,  hereafter,  be  spoken  of  as  "com- 
pound calomel  powder,"  the  formula  for  the  same 
being  given  under  this  name  in  the  "  Appendix." 

The  good  effects  of  this  "  unloading  of  the  primae 
viae,"  as  the  older  writers  used  to  express  it,  are,  as  a 
rule,  promptly  manifested,  and  it  will  sometimes  happen 
that  the  case  is  well  on  the  way  to  recovery  before 
other  treatment  (apart  from  the  yellow  oxid  ointment, 
which  should  be  prescribed  when  the  purgative  is 
ordered)    is   begun.     The   most   useful   tonic   in   these 


DISEASES    OF    THE     EYELIDS    AND    ORBIT.  67 

cases  is  a  combination  of  the  phosphates  of  iron, 
quinin,  and  Strychnin.*  Exceptionally,  in  distinctly 
strumous  subjects,  exhibiting  enlarged  lymphatic  glands, 
etc.,  the  syrup  of  the  iodid  of  iron  or  one  of  the  cod- 
liver  oil  emulsions  may  answer  a  better  purpose. 

From  what  has  been  said  regarding  the  frequent 
dependence  of  blepharitis  upon  errors  of  refraction, 
it  is  obviously  the  duty  of  the  physician  when  he  meets 
with  an  intractable  case  of  this  affection,  to  direct  the 
patient,  without  unnecessary  delay,  to  a  competent 
specialist,  in  order  that  the  glasses,  which  it  is  probable 
are  urgently  demanded,  may  be  prescribed. 

Hordeolum  (Stye). — Styes  are  of  such  common 
occurrence  that  every  physician  is  familiar  with  their 
appearance.  Very  considerable  diffuse  edema  of  the 
lid  commonly  marks  the  incipient  stage  of  a  stye. 
Presently,  at  some  point  near  the  lid-margin  a  more 
defined  swelling,  attended  by  redness  and  tenderness, 
makes  its  appearance.  Within  a  day  or  two  suppura- 
tion takes  place  at  this  pomt,  the  overlying  tissue 
softens,  and  there  occurs  a  slight  discharge  of  thickish 
pus.  The  pain,  perhaps  quite  severe,  which  has  been 
experienced  up  to  this  time  now  quickly  subsides, 
and  here  the  trouble  may  end.  However,  so  fortunate 
an  outcome  as  this  is  rather  exceptional,  for  styes  are, 
so  to  speak,  gregarious,  and  when  one  has  made  its 
appearance  others  are  apt  to  follow.  The  explanation  of 
this  is  not  far  to  seek,  when  we  consider  their  etiology. 
Almost  invariably  styes,  which  are  simply  furuncles 
occurring  in  the  lids,  have  their  starting-point  in  some 
one  of  the  numerous   glands  with  which   the  eyelids 

*  The  elixir  of  the  phosphates  of  iron,  quinin  and  strychnin  pre- 
pared by  Wyeth  and  Bro.  and  a  syrup  of  about  the  same  strength 
made  by  Sharp  and  Dohme  are  especially  to  be  commended. 


68 


PREVALENT    DISEASES    OF    THE    EYE. 


are  so  plentifully  supplied  (Fig.   14).     The  conditions 
being  such  as  to  favor  its  development,  the  Staphylococ- 


b  / 

Fig.  14. — Vertical  section  through  the  upper  eyehd  (Waldeyer) : 
a.  Skin;  b,  cut  fibers  of  the  orbicularis;  b',  ciliar}- bundle  of  orbicularis; 
c,'muscle  (involuntary)  of  Miiller;  d,  conjunctiva;  e,  tarsal  plate  in  which 
are  embedded  the  meibomian  glands  (/);  g,  sebaceous  glands  near  cilia 
{h);  /,  small  hairs  of  integument ;  /,  sweat-glands;  ^,  posterior  tarsal  glands. 

cus  aureus,  or  some  other  p\'ogenic  organism,  invades 
one  of  the  meibomian,  or  one  of  the  sebaceous,  glands 
or  the  follicle  of  an  eyelash,  and  the  inflammator\'  pro- 


DISEASES    OF    THE    EYELIDS    AND    ORBIT.  69 

cess  IS  Started.  Suppuration  once  established, the  infec- 
tion of  other  glands  is  almost  sure  to  occur,  and  so  it 
happens  that  a  sequence  of  styes  is  the  rule  rather 
than  the  exception. 

The  existence  of  blepharitis  marginalis  is  the  most 
common  predisposing  cause  of  styes.  Accommodative 
strain  is  another  predisposing  cause;  for,  even  when  it 
does  not  excite  an  actual  blepharitis,  it  is  apt  to  induce 
a  hyperemic  condition  of  the  lids  v^hich  favors  furun- 
culosis.  A  "run-down"  state  of  the  system  also  may 
be  a  cause  of  styes,  as  it  may  be  of  furuncles  in  other 
regions.  Habitual  constipation  is  still  another  predis- 
posing cause. 

Treatment. — Prophylactic:  Whether  blepharitis  be 
present  or  not,  the  history  of  repeated  attacks  of  styes 
should  suggest  the  probable  existence  of  accommo- 
dative strain.  Therefore,  in  all  such  cases  a  careful 
test  of  the  refraction  should  be  made.  If  blepharitis 
exists,  the  yellow  oxid  ointment  should  be  prescribed 
and  should  be  used  systematically.  This  ointment  is 
also  useful,  since  it  lessens  the  danger  of  secondary 
infections,  in  preventing  the  recurrence  of  styes.  For 
overcoming  habitual  constipation  aloin,  in  doses  of 
a  tenth  to  a  fifth  of  a  grain,  at  bedtime,  is  especially 
efficacious. 

Abortive:  If  a  stye  is  seen  in  its  incipiency,  it  is 
usually  possible  to  prevent  its  development.  One  way 
of  doing  this  is  to  apply  a  strong  solution  of  sulphate 
of  zinc  (gr.  xxx  to  ,=5  j)  to  the  external  surface  of  the 
eyelid,  over  the  sensitive  region  where  it  is  evident 
the  stye  is  about  to  form.  To  be  effectual  the  applica- 
tions must  be  frequently  repeated — at  intervals  of  half 
an  hour  throughout  the  day.  The  solution  may  be 
applied  with  the  tip  of  the  finger,  care  being  exercised 


70  PREVALENT    DISEASES    OF    THE     EYE. 

to  prevent  its  flowing  into  the  eye,  as  this  would  cause 
considerable  irritation.  A  few  fibers  of  absorbent 
cotton  placed  over  the  region  of  the  stye  will  adhere  to 
the  surface  of  the  lid  after  having  been  once  w^et,  and, 
by  holding  a  greater  quantity  of  the  solution  in  contact 
with  it,  will  make  the  application  more  efl&cacious. 

Another  method  of  aborting  a  stye  is  to  introduce 
a  minute  quantity  of  pure  carbolic  acid  into  the  in- 
fected follicle.  A  careful  inspection  of  the  margin  of 
the  lid  will  frequently  show  which  follicle  is  involved, 
for  the  orifice  of  the  infected  follicle  will  be  either 
slightly  swollen  and  congested  or  there  will  be  a  little 
discharge  oozing  from  it.  When  this  has  been  determ- 
ined, a  wooden  toothpick,  made  quite  slender  and  sharp- 
pointed,  should  be  dipped  mto  carbolic  acid  and  insinu- 
ated, as  far  as  practicable,  into  the  follicle.  One  should, 
of  course,  be  careful  to  prevent  the  acid  coming  in 
contact  with  the  eye;  but  this  is  not  likely  to  happen 
if  the  toothpick  is  slender,  and  the  precaution  is  taken 
to  shake  off  any  excess  of  the  acid  from  its  tip.  This 
procedure  is  usually  effectual,  if  resort  to  it  is  not 
too  long  delayed. 

When  it  is  evident  that  abortive  treatment  is  not 
likely  to  be  successful,  the  suppurative  process  should 
be  hastened  by  the  application  of  poultices  or  hot 
fomentations,  and  as  soon  as  pus  has  formed  it  should 
be  evacuated  by  an  incision  made,  with  a  keen-edged 
and  sharp-pointed  knife,  parallel  to  the  border  of  the 
lid.  For  this  purpose  the  old-fashioned,  triangular 
cataract  knife  or  a  Graefe  cataract  knife  is  well  adapted. 
As  soon  as  the  pain  and  discharge  have  abated  the 
poultices  should  be  discontinued,  and  the  ointment  of 
yellow  oxid  of  mercury  (gr.  ij  to  "vaselin  cerate"  oj) 
should  be  used  instead.     This  will  not  only  tend  to 


DISEASES    OF    THE    EYELIDS    AND    ORBIT.  7I 

dissipate  the  remaining  inflammation  and  induration; 
but,  as  has  already  been  said,  will,  perhaps,  prevent 
the  development  ot  other  styes.  When  the  system 
needs  building  up  the  tonics  likely  to  prove  most  useful 
are  the  tincture  of  chlorid  of  iron,  the  elixir  of  phos- 
phates of  iron,  quinin,  and  strychnin  (as  recommended 
in  blepharitis),  and  the  well-known  combination  of 
quinin,  carbonate  of  iron,  and  nux  vomica,  which  may 
be  given  conveniently  in  capsules  or  in  pills.  When 
a  purgative  is  indicated,  which  is  not  infrequently  the 
case,  the  "compound  calomel  powder"  will  be  found 
to  answer  an  excellent  purpose. 

Eczema. — Eczema  of  the  eyelids  is  commonly 
associated  with  eczema  upon  other  parts  of  the  face; 
it  is  also  a  not  infrequent  accompaniment  of  phlyctenu- 
lar ophthalmia  (Fig.  15).  Epiphora,  due  to  malposition 
of  the  lacrimal  puncta  or  to  stricture  of  the  nasal  duct, 
often  causes  an  eczema  of  the  lower  lid  and  occasionally 
of  the  cheek,  the  skin  being  irritated  by  the  constant 
overflow  of  tears  and  mucus.  Eczema  limited  to  the 
inner  canthus,  and  less  often  to  the  outer  canthus,  is  not 
uncommon.  When  occurring  in  the  former  position, 
it  is  usually  dependent  upon  inflammation  of  the  lac- 
rimal passages  or  upon  chronic  rhinitis.  In  children 
eczema,  like  phlyctenular  conjunctivitis,  is  often  due  to 
faulty  digestion  consequent  upon  improper  food  and 
unsanitary  surroundings;  in  adults  it  may  be  dependent 
upon  a  gouty  diathesis. 

Treatment. — The  ointments  of  yellow  oxid  of  mer- 
cuiy  and  of  salicylic  acid,  as  recommended  in  blephar- 
itis, marginalis,  are  the  most  useful  local  remedies. 
Another  useful  application  is  an  ointment  of  oxid  of 
zinc  and  boracic  acid  (zinci  oxid.,  gr.  ij;  acid,  boracic, 
gr.  iv;    ung.  aquae  rosae,  oj).     If  the  eczema  is  caused 


72 


PRKVAI.ENT    DISEASES    OF    THE     EYE. 


by  epiphora,  this  must  be  remedied.  If  the  overflow 
of  tears  is  due  to  malposition  (usually  eversion)  of  the 
puncta,  the  lower  canaliculus  must  be  slit;  if  dependent 
upon  occlusion  of  the  lacrimal  duct,  this  must  be  over- 
come by  the  systematic  use  of  probes,  as  described  in 
the  succeeding  chapter. 

The  condition  of  the  general  health  should  also  be 


l-ig.    is.-E.-.: 


-;  ,.:.  1  f-iL'j,  v.iih  associated  phlyctenular  con- 
junctivitis (Haab). 


looked  to — the  bowels  should  be  opened,  the  diet 
regulated  and  suitable  tonics  administered.  When 
gout  is  present,  the  natural  lithia  waters  will  be  found 
beneficial.  Especially  when  the  eczema  is  limited  to 
the  margin  of  the  lids,  and  has  existed  for  a  consider- 
able time,  accommodative  strain  should  be  suspected, 
and  the  refractive  condition  of  the  eyes  should  be 
looked  into. 


PLATE   1. 


/ 


y-X 


4 


>^<ol^ll 


V 


Chalazion  of  the  Upper  Lid. 


DISEASES    OF    THE     EYELIDS    AND    ORBIT.  73 

Chalazion  (Tarsal  Cyst). — An  acute  inflammation 
of  a  meibomian  gland,  ending  in  suppuration,  consti- 
tutes, as  has  been  said,  one  variety  of  stye.  A  chronic 
inflammation  of  one  of  these  glands,  or  an  inflammation 
which,  though  acute  at  the  outset,  does  not  go  on  to 
suppuration,  frequently  leads  to  the  development  of 
a  chalazion  or  tarsal  cyst.  A  chalazion,  after  slowly 
increasing  in  size  for  some  weeks,  or  even  for  several 
months,  until  it  becomes,  perhaps,  larger  than  a  large 


Fig.  16. — Vertical  section  of  chalazion  (meibomian  cyst);  X  10, 
glycerin:  i,  Stratified  epithelium  continued  over  the  surface;  2,  connec- 
tive-tissue outside  tumor;  3,  capsule  of  fibrous  tissue  from  which  septa 
pass  inward,  dividing  the  cyst  into  lobules;  4,  epithelial  cells  inside  capsule; 
5,  fatty  material  occupying  center  of  lobules,  the  outer  layers  being  more 
opaque  (Pollock). 

split  pea,  and  forms  upon  the  outer  surface  of  the  lid 
a  conspicuous  httle  tumor,  often  oval  in  shape,  with 
its  long  axis  vertical  (in  correspondence  with  the  direc- 
tion of  the  folhcle)  (see  Plate  I),  not  infrequently 
opens  upon  the  conjunctival  aspect  of  the  lid — a  rather 
lame  effort  of  nature  to  bring  the  process  to  an  end. 
Before  this  occurs  the  contents  of  the  cyst,  previously 
gelatinous,  and  consisting  of  the  retained  and  altered 
secretions  of  the  gland,  usually  become  purulent  (Fig. 


74  PREVALENT    DISEASES    OF    THE     EYE. 

i6).  After  the  perforation  takes  place  a  slight  discharge 
from  the  cyst  may  continue  for  an  indefinite  period,  and 
very  often  granulations  sprout  up  from  the  edges  of  the 
fistula-like  opening  through  which  the  discharge  escapes. 
In  rare  instances  the  anterior  wall  of  the  cyst  breaks 
down,  and  its  contents  are  discharged  through  the 
dermal  surface  of  the  lid. 

Before  the  stage  of  perforation  is  reached,  the  chala- 
zion, unless  it  has  become  large  enough  to  increase 
appreciably  the  weight  of  the  lid  or  to  interfere  with 
its  movements,  gives  rise  to  but  little  inconvenience, 
apart  from  its  unsightliness;  but,  after  the  perforation 
occurs,  and  especially  if  granulations  have  formed, 
it  causes  more  discomfort,  partly  from  the  discharge 
spreading  over  the  cornea  and  partly  from  the  mechan- 
ical irritation  produced  by  the  presence  of  the  granula- 
tions. Chalazia  form  rather  more  frequently  in  the 
upper  than  in  the  lower  lid,  are  prone  to  recurrence, 
though  not  in  the  same  follicle,  are  often  multiple, 
several  occurring  simultaneously  in  the  lids  of  one 
or  both  eyes,  and  are  most  common  in  early  adult  life. 
The  existence  of  chronic  blepharitis  marginalis  is  a 
distinctly  predisposing  cause,  and  so  also,  though  less 
directly,  is  accommodative  strain.  As  may  be  inferred 
from  what  has  been  said  regarding  their  etiology,  they 
are  often  encountered  in  persons  who  are  subject  to 
styes. 

Treatment. — It  is  sometimes  possible  to  dissipate 
a  chalazion,  which  is  small  and  has  only  recently 
formed,  by  the  application  of  the  ointment  of  the 
yellow  oxid  of  mercury  or  the  ordinary  mercurial 
ointment;  but,  as  a  rule,  the  only  effectual  method  of 
treatment  is  operative  The  suggestion,  often  met  with 
in    text-books    upon    the    eye,    that     chalazia    should 


DISEASES    OF    THE    EYELIDS    AND    ORBIT.  75 

be  "dissected  out"  is  ridiculous  and  should  not  be 
followed,  because,  in  the  first  place,  owing  to  the  thin- 
ness of  the  cyst  w^alls  it  is  an  almost  impossible  pro- 
cedure and,  in  the  next  place,  it  involves  a  very  un- 
necessary traumatism  of  the  eyelid.  Except  in  rare 
instances,  when  the  cyst  is  very  superficial  and  shows 


Fig.   17. — Chalazion  knife  and  sharp  curet  (about  two-thirds  actual  size). 

a  disposition  to  break  through  the  skin,  they  should 
be  attacked  from  the  inner  surface  of  the  lid.  When 
the  lid  is  everted,  a  circumscribed  purplish  area  is 
observed.  This  marks  the  location  ot  the  cyst,  which 
will  be  found  directly  beneath  it,  and  indicates  the 
point  at  which  the  incision  should  be  made. 


Fig.   18. — Operation  for  chalazion.     Crucial  incision  into  sac  through  con- 
junctival aspect  of  lid. 

The  operation  which  I  have  found  effectual,  and 
which  is  very  easy  of  performance,  is  as  follows:  The 
eye  having  been  anesthetized  by  several  applications  of 
cocain  and  adrenalin  solution  (i  :  1000), the  lid  is  everted 
and  held  securely  in  this  position,  either  with  or  without 
the  aid  of  a  lid-clamp,  as  may  be  preferred.     With  a 


76  PREVALENT    DISEASES  OF    THE    EYE. 

knife  such  as  is  shown  in  the  illustration  (Fig.  17)  a 
crucial  incision  (the  cuts  being  about  4  mm.  in  length) 
is  made  directly  into  the  cyst  (Fig.  18).  The  contents 
of  the  cyst  are  then  removed  with  a  sharp  spoon  (also 
shown  in  Fig.  17),  and  in  doing  this  its  walls  are 
thoroughly  scraped  (Fig.  19).  The  small,  bulbous  tip 
of  a  silver  probe,  which  has  been  previously  coated 
with  silver  nitrate  by  being  heated  in  a  flame  and 
brought  in  contact  with  a  crystal  or  crayon  of  lunar 


Fig.  19. — Removing  contents  of  sac  and  curetting  its  walls  with  sharp  spoon. 

caustic,  is  now  introduced  into  the  cyst,  and  moved 
about  so  as  to  cauterize  it  thoroughly  (Fig.  20).  This 
completes  the  operation,  and  the  lid,  after  having  been 
washed  clean  with  sterile  water  or  a  solution  of  boracic 
acid,  is  allowed  to  resume  its  normal  position.  No  after- 
dressing  is  required,  but  it  is  a  good  plan  to  apply  a 
poultice  of  flaxseed-meal  to  the  lids  the  succeedmg 
night.  Considerable  inflammatory  reaction  follows 
the  operation;    but  this  subsides  quickly,  leaving  some 


DISEASES  OF    THE     EYELIDS    AND    ORBIT. 


11 


induration  which  disappears  in  the  course  of  a  few 
weeks.  The  curetting  and  cauterization  are  necessary 
to  prevent  a  re-formation  of  the  cyst.  The  smaller 
the  chalazion,  the  more  difficult,  as  a  rule,  is  the  opera- 
tion. When  the  chalazion  is  in  the  lower  lid,  the 
operation  is  also  rather  more  difficult.  In  operating 
through  the  external  surface  of  the  lid  the  same  pro- 
cedure is  followed. 

Milium  is  the  name  given  to  a  variety  of  sebaceous 


Fig.  20. — Cauterizing  walls  of  sac  with  silver  nitrate  fused  upon  bulbous 
tip  of  silver  probe. 


cyst,  about  the  size  of  a  millet-seed  (hence  the  term), 
which  occurs  in  the  eyelid.  It  is  white  in  color,  round- 
ish, and  slightly  prominent.  It  causes  no  especial 
inconvenience,   but   is    rather   unsightly. 

Treatment. — It  should  be  incised,  the  sebaceous 
contents  removed  with  a  small  curet,  and  the  cyst 
wall  peeled  out  with  slender,  toothless  forceps.  It 
exhibits  but  little  tendency  to  recur,  when  dealt  with  in 
this  way. 


78 


PREVALENT    DISEASES    OF    THE     EYE. 


Hydrocystoma. — Small,  translucent  cysts,  contain- 
ing a  clear,  watery  fluid,  are  occasionally  observed  in 
the  lid.  They  result  from  occlusion  of  the  duct  of  a 
sweat-gland,  and  may  be  gotten  rid  of  by  simple  in- 
cision or,  more  surely,  by  excising,  with  slender  curved 
scissors,  the  outer  half  of  the  cyst  wall. 

Warts,  usually  of  small  size,  are  not  uncommon 
upon   the   lids.     They   are   found   generally   upon   the 


Fig.  21. — Epithelioma  of  the  eyeHd    (Ramsay). 


lid-margin,  about  the  roots  of  the  eyelashes.  They 
are  unsightly,  but  otherwise  cause  no  inconvenience. 
They  should  be  snipped  off  with  curved  scissors,  and, 
to  lessen  the  possibility  of  a  recurrence,  the  base 
should  be  cauterized  with  a  pointed  cravon  of  silver 
nitrate. 

Malignant  tumors  of  the  evelid  are  rare,  if  we  ex- 
cept epithelioma,  which  is  prone  to  occur  here,  as  it 
does  in  other  regions  of  the  body  where  the  skin  and 
mucous  membrane    join    (Fig.  21).     They    should  be 


DISEASES    OF    THE    EYELIDS    AND    ORBIT. 


79 


dealt  with  promptly  and  radically,  as  they  tend  to 
invade  the  orbit  (Figs.  23  and  24),  causing  not  only  loss 
of  sight  but  loss  of  life  from  secondary  involvement 
of    the    brain.     They    afford    an    especially  favorable 


Fig.  22. — Syphilitic   tarsitis  (de  Schweinitz). 


field  for  the  Rontgen-ray  treatment,  provided  this  is 
employed  before  extension  to  the  orbit  has  occurred. 
Tarsitis,  or  inflammation  of  the  tarsal  cartilage, 
characterized  by  hyperemia  and  nodular  swelling  of 
the  lid,  is  commonly  dependent  upon  acquired  syphilis, 
occurring  in  the  tertiary  stage  of  the  disease  (Fig.  22). 


8o 


PREVALENT    DISEASES    OF    THE     EYE. 


It  tends  to  run  a  chronic  course,  and  is  frequently 
accompanied  by  palpebral  conjunctivitis. 

Constitutional  as  well  as  local  treatment  is  called  for. 
The  biniodid  ot  mercury,  m  doses  of  ^V  ^^  tV  ^^  '^ 
grain,  three  times  a  day,  and  the  yellow  oxid  ointment, 
applied  to  the  lid  morning  and  night,  are  the  remedies 
indicated. 

Entropion,  inversion  of  the  eyelid,  a  very  annoying 


Fig.  23. — Sarcoma  of 
the  lid  and  orbit  (Frieden- 
wald). 


Fig.  24. — Dr.  Friedenwald's  case 
of  sarcoma  of  the  lid  and  orbit  three 
months  after  operation.* 


condition  because  the  eyelashes  come  into  contact 
with  the  cornea,  causing  much  irritation  and  not  infre- 
quently superficial  keratitis,  occurs  under  two  forms, 
one  variety  being  known  as  spasmodic^  the  other  as 
orga77ic  or  cicatricial  entropion. 

*The  description  of  this  case  will  be  found  in  the  "Trans.  Am. 
Ophthalmological  Soc."  for  igoo.  There  was  no  local  recurrence 
of  the  disease  ;  but  Dr.  Friedenwald  informs  me  the  patient  died 
fifteen  months  after  the  date  of  the  operation,  with  symptoms  indi- 
cative of  metastatic  involvement  of  the  right  lung. 


DISEASES    OF    THE     EYELIDS    AND    ORBIT.  8l 

Spasmodic  entropion,  as  its  name  implies,  results 
usually  from  undue  contraction  ot  the  orbicularis  mus- 
cle, commonly  dependent  upon  photophobia.  It  oc- 
curs also  as  a  senile  condition,  arising  from  relaxation 
of  the  lid-structures,  and  occasionally  develops  as  a 
result  of  bandaging  the  eyes  after  operations,  such  as 
cataract  extraction.  A  predisposing  cause — some  fault, 
perhaps,  in  the  form  or  firmness  of  the  tarsal  cartilage 
or  in  the  arrangement  of  the  orbicularis  muscle — it 
would  seem  probable,  is  always  present. 

Organic  entropion  is  produced  by  the  contraction 
of  scar-tissue  in  or  beneath  the  palpebral  conjunctiva, 


V     Vi'"-'* 


Fig.  25. — Incomplete    entropion    of   the    upper   lids    with    consequent   tri- 
chiasis (de   Schweinitz). 

and  almost  invariably  is  dependent  upon  chronic 
trachoma;  exceptionally  it  is  of  traumatic  origin. 
Both  the  upper  and  lower  lids  are  liable  to  be  involved. 
When,  however,  the  fault  is  consequent  upon  trachoma, 
it  is  usually  the  upper  lid  that  is  most  in-turned,  and 
causes  the  greatest  amount  of  trouble  (Fig.  25).  On 
the  other  hand,  the  lower  lid  is  almost  always  affected 
in  senile  entropion,  and,  indeed,  in  the  several  varieties 
of  spasmodic  entropion  it  is  commonly  the  lower  lid 
that  is  misplaced. 

The  treatment  of  entropion,  which  has  for  its  object 
the  replacement  of  the  lid  in  its  normal  position,  differs 

6 


82  PREVALENT    DISEASES    OF    THE     EYE. 

materially  in  the  different  types  of  the  affection;  the 
procedure  to  be  adopted  depends  also  upon  whether 
the  upper  or  the  lower  lid  is  involved.  In  spasmodic 
entropion,  including  the  senile  type,  if  the  fault  has 
existed  only  a  short  time,  it  is  often  possible  to  effect 
a  cure  by  putting  the  lid  in  its  normal  position,  and 
keeping  it  there  for  some  days.  When  only  the  upper 
lid  is  involved,  this  may  be  accomplished  by  the  careful 
application  of  a  pressure  bandage.  A  more  effectual 
method  of  preventing  the  in-turning — applicable,  espe- 
cially, to  the  lower  lid — is  the  painting  of  several  coats 
of  contractile  collodion  upon  the  loose  skin  of  the  lid. 
The  application  must  be  repeated  often  enough  to 
keep  the  lid  constantly  in  proper  position — usually  once 
in  two  or  three  days.  The  collodion  will  "hold"  very 
much  better  if,  before  applying  it,  the  skm  is  sponged 
with  alcohol  or  ether. 

When  these  expedients  fail  to  remedy  the  defect, 
resort  must  be  had  to  one  of  the  many  operations 
which  have  been  devised  for  the  cure  of  entropion. 

The  procedure  best  adapted,  in  my  judgment,  to 
the  correction  of  inversion  of  the  lotver  lid — whether 
due  to  trachoma  or  of  spasmodic  origin — is  one  that, 
in  recent  years,  at  all  events,  has  not  received  the  con- 
sideration which,  I  think,  it  deserves.  I  refer  to  the 
production  of  a  linear  eschar  near  the  margin  of  the 
lid  by  the  application  of  caustic  potash.  My  ex- 
perience with  this  operation — if  it  deserves  to  be  called  an 
operation — has  been  most  satisfactory,  and  has  induced 
me,  heretofore,  to  point  out  its  merits.*  The  aim  is  to 
produce  an  eschar,  4  or  5  mm.  wide,  parallel  with  the 

*  In  a  paper  published  in  the  "Transactions  of  the  American 
Ophthalmological  Society"  for  the  year  1898,  and  in  the  "American 
Journal  of  Ophthalmology,"  October,  1898. 


DISEASES    OF    THE     EYELIDS    AND    ORBIT.  83 

lid-margin  and  extending  nearly  the  whole  length  of 
the  tarsus,  the  contraction  resulting  from  which  shall 
hold   the   lid    in    its    normal    position. 

In  order  that  the  caustic  may  be  applied  with  the 
requisite  degree  of  exactness,  one  end  of  the  crayon 
employed  must  be  carefully  sharpened.  This  is  easily 
accomplished  by  rubbing  it  upon  wet  blotting-paper. 
The  very  considerable  pain  caused  by  the  action  of 
the  caustic  may  be  materially  lessened  by  soaking  the 
lid  for  ten  or  fifteen  minutes  with  a  ten  per  cent,  solu- 
tion of  cocain,  applied  by  means  of  a  pledget  of  ab- 
sorbent cotton.  As  the  destruction  of  tissue  tends  to 
spread  considerably  beyond  the  point  w^here  the  caustic 
is  applied,  and  as  it  is  desirable  that  this  should  not 
approach  nearer  the  lid-margin  than  i|  or  2  mm., 
the  line  of  application  of  the  crayon  should  be  about 
4  or  5  mm.  from  the  ciliary  border.  Along  this  line, 
the  lid  being  held  upon  the  stretch  and  pulled  away 
from  the  eyeball,  the  point  of  the  crayon  should  be 
drawn,  back  and  forth,  a  number  of  times,  until  the 
epidermis  is  destroyed  and  the  tissues  beneath  assume 
a  brownish  appearance  (Fig.  26).  The  lid  being  still 
held  so  that  it  shall  not  become  inverted,  the  action  of 
the  caustic  is  allowed  to  extend  as  far  as  may  seem  de- 
sirable. When  this  point  is  reached,  its  further  action  . 
is  arrested  by  the  application  of  vinegar  and  water,  equal 
parts,  or  acetic  acid  diluted  with  water  to  about  an 
equivalent  strength.  Within  a  few  minutes  the  eschar 
begins  to  contract,  and  the  lid  may  then  be  released 
vvithout  fear  of  its  turning  in,  as  already,  in  most 
instances,  the  tendency  to  entropion  has  been  overcome. 

It  is  seldom  necessary  to  repeat  the  application  of 
the  caustic;  but  this  can  be  readily  done,  it  the  eflfect 
of  the  first  application  has  proved  insufficient.     Within 


84 


PREVALENT    DISEASES    OF    THE     EYE. 


a  few  weeks  all  traces  of  the  eschar  have  disappeared, 
and  usually  it  is  not  possible  to  detect  that  any  opera- 
tion  has   been   performed. 

In  entropion  of  the  upper  lid  the  procedure  just 
described  is  not  effectual;  for  the  cartilage  of  the  upper 
lid,  which  is  broader  and  thicker  than  that  of  the  lower 
lid  (Fig.  2"),  usually  plays  a  more  essential  part  in  the 
production  of  the  deformity,  so  that  not  much  can 
be  expected  of  any  operation  which  accomplishes  little 


Fig.  26. — The  correction  of  entropion  of  the  lower  lid  by  the   production 
of  an  eschar  with  caustic  potash. 


else  than  the  removal  ot  a  portion  of  the  external  in- 
tegument. However,  in  spasmodic  entropion  of  the 
upper  lid,  which,  as  has  been  said,  is  a  condition  sel- 
dom encountered,  if  the  skin  of  the  lid  is  redundant, 
it  is  sometimes  possible  to  correct  the  fault  bv  the 
simple  excision  of  a  semilunar  piece  of  the  integu- 
ment, which  is  done  in  the  following  manner:  A  lid- 
spatula  is  placed  beneath  the  lid,  to  support  it,  and 
two  incisions  are  made  through  the  skin,  one  parallel 


DISEASES    OF    THE     EYELIDS    AND    ORBIT. 


S5 


with  and  about  2  mm.  from  the  Hne  of  the  lashes, 
extending  nearly  the  whole  length  of  the  tarsus;  the 
other  curvilinear,  and  reaching  from  one  end  to  the 
other  ot  the  first  incision.  The  degree  of  upward 
curve  of  the  second  mcision  will  depend  upon  the 
amount  of  integument  it  is  thought  desirable  to  excise. 
The  skin  lying  between  the  two  incisions  and  a  portion 


%^OiM 


1 I- -12 


Fig.  27. — Dissection  of  the  tarsal  plates  and   their  ligaments    (Testut): 

I,  2,  Upper  and  lower  tarsus;  3,  4,  external  and  internal  tarsal  ligaments; 
5,  expanded  tendon  of  levator  palpebrae;  6,  6',  septum  orbitale;  7,  lacrimal 
sac;    8,  supraorbital  vessels  and    nerve;    q,  lacrimal  artery   and  nerv-e;    10, 

II,  openings  for  supratrochlear  and  infratrochlear  nerves;  12,  opening 
for  the  angular  vein;    13,  tendon  of  superior  oblique  muscle. 

of  the  orbicularis  muscle  beneath  it  are  next  removed, 
with  the  knife  or  scissors  as  may  be  preferred,  and  the 
operation  is  completed  by  bringing  together  the  edges 
of  the  wound  with  three  or  four  fine  silk  sutures. 
After  three  days  union  will  have  taken  place,  and  the 
stitches  may  be  removed. 

In  the  so-called  organic  entropion  of  the  upper  lid — 
that  form  which  is  commonly  induced  by  trachoma — 


86  PREVALENT    DISEASES    OF    THE     EYE. 

a  more  radical  procedure  than  the  foregoing  is  de- 
manded. 

The  operation  which  I  have  most  frequently  em- 
ployed in  this  condition,  and  usually  with  satisfactory 
results,  is  that  which  was  suggested  some  years  ago 
by  Dr.  John  Green,  of  St.  Louis.  It  is  open  to  the 
objection,  however,  that  it  necessarily  involves  a  very 
considerable  traumatism  of  the  tarsal  cartilage  and 
of  the  palpebral  conjunctiva,  and  it  has  been  largely 
supplanted  by  the  procedure  originally  proposed  by 
Anagnostakis,  but  which  commonly  goes  by  the  name 
of  Dr.  Hotz,  of  Chicago,  who,  without  knowledge  of 
what  had  been  done  in  this  direction  by  Anagnostakis, 
re-contrived  and  perfected  the  operation,  and  brought 
its  merits  to  the  notice  of  the  ophthalmic  surgeons  of 
the  present  day. 

Dr.  Hotz's  description  of  the  operation,  made  very 
easy  of  comprehension  by  the  accompanying  excellent 
illustrations  (Fig.  28),  for  which  I  am  indebted  to  him, 
is  as  follows: 

"While  an  assistant  fixes  the  skin  at  the  supraorbital  margin  the 
operator,  seizing  the  center  of  the  hd-border  with  fingers  or  forceps, 
draws  the  hd  downward  to  put  its  skin  well  on  a  stretch,  and  makes 
a  transverse  incision  through  the  skin  and  orbicularis  muscle  from 
a  point  2  or  3  mm.  above  the  punctum  lachrymale  to  a  point  2  or 
3  mm.  above  the  external  canthus.  This  incision  (Fig.  28,  A)  divides 
the  lid-skin  in  a  line  parallel  to  and  a  little  below  the  upper  border 
of  the  tarsal  cartilage,  and  is  therefore  from  4  to  8  mm.  distant  from 
the  free  border  in  the  center  of  the  lid.  The  skin  and  muscular  layer 
are  now  dissected  from  the  incision  down  to  the  roots  of  the  eye- 
lashes, and,  while  an  assistant  is  holding  the  edges  of  the  wound 
well  separated,  the  operator  seizes  with  forceps  and  excises  with 
curved  scissors  the  muscular  fibers  running  transversely  across  the 
upper  border  of  the  tarsus.  Next  the  sutures  are  inserted.  Three 
sutures  are  usually  sufficient — one  in  the  center  of  the  wound  and 
one  at  each  side  of  the  central  suture.  The  curved  needle,  armed 
with  black  silk  No.  3,  is  first  passed  through  the  wound-border  of 
the  lid-skin  (A,  a);  then  it  is  thrust  through  the  upper  border  of  the 
tarsus  and  returned  through   the  tarso-orbital  fascia   just   above  this 


DISEASES    OF    THE     EYELIDS    AND    ORBIT. 


^7 


border;  and  finally  it  is  carried  through  the  upper  wound-border 
(b).  When  the  sutures  are  tied  the  skin  is  drawn  upward  and  fixed 
to  the  upper  tarsal  border  (Fig.  28,  B),  and  this  slight  traction  is 
sufficient  to  turn  the  inverted  lid-border  and  eyelashes  to  their 
normal  position;  and,  as  the  skin  becomes  firmly  united  with  the 
tarsal  border,  the  tension  thus  produced  upon  the  lid-border  is  per- 
manently secured." 

Under  aseptic  dressings  the  wound  commonly  heals 
without  suppuration,  and  the  stitches  may  be  removed 
on  the  third  or  fourth  day. 


Fig.  28. — A  and  B,  Anagnostakis-Hotz  operation  for  entropion. 

In  the  worst  forms  of  entropion  Dr.  Hotz  combines 
with  the  procedure  just  described  a  "reconstruction 
of  the  hJ-fnargtn."  A  deep  incision  is  made  in  the 
free  border  of  the  lid,  extending  nearly  its  whole  length 
and  just  behind  the  line  of  the  lashes,  great  care  being 
exercised  that  no  lashes  are  left  in  the  posterior  lip  of 
the  divided  lid-margin.  The  tension  of  the  external 
integument  of  the  lid  produced  by  its  attachment  to 
the   upper   margin   of  the   tarsal  cartilage  causes  this 


88  PREVALENT    DISEASES    OF    THE     EYE. 

incision  to  gape  considerably,  and  this  gap  is  filled 
by  a  Thiersch  graft — a  narrow,  wedge-shaped  strip  of 
skin,  of  suitable  length,  which  may  be  obtained  con- 
veniently from  the  posterior  surface  of  the  auricle  or 
from  the  integument  which  covers  the  mastoid  process. 
Sutures  are  not  necessary  to  retain  the  graft  in  position; 
but  it  is  desirable  to  bandage  both  eyes — for  twenty- 
tour  or  forty-eight  hours — until  it  has  become  adherent. 

Ectropion. — Like  entropion,  eversion  of  the  eyelid, 
or  ectropion,  may  be  produced  by  spasm  of  the  orbicu- 
laris muscle,  by  contraction  of  scar  tissue,  or  by  senile 
relaxation  and  loss  of  tone  of  the  lid-structures.  It 
may  occur  also  in  consequence  of  paralysis  of  the 
orbicularis  muscle.  Both  lids,  the  upper  and  the 
lower,  are  liable  to  be  affected,  the  less  pronounced 
forms  being  found,  as  a  rule,  when  the  displacement 
is  in  the  lower  lid;  for  the  degree  of  eversion,  it  should 
be  remarked,  varies  greatly — from  a  slight  drooping 
of  the  lower  lid,  just  sufficient  to  cause  eversion  of  the 
punctum  and  consequent  epiphora,  to  complete  turning 
out  of  the  conjunctival  surface  of  the  lid,  giving  rise 
to  a  revolting  deformity.  The  slighter  forms,  affecting 
the  lower  lid,  are  those  which  result  from  senile  changes, 
from  paralysis  of  the  orbicularis,  and  from  eczema  of 
the  lid  and  cheek.  The  more  pronounced  types  are 
due  to  spasm  of  the  orbicularis  or  to  cicatricial  con- 
traction. 

Spasmodic  ectropio7i  develops  usually  during  the 
course  of  an  acute  conjunctivitis  or  kerato-conjunctivi- 
tis,  attended  by  congestion  and  edema  of  the  palpebral 
conjunctiva.  As  a  rule,  these  conditions  are  accom- 
panied by  photophobia  and  blepharospasm.  When 
an  attempt  is  made  to  examine  such  eves,  or  to  make 
applications  to  them,  it  is  not  uncommon  for  the  lids, 


DISEASES    OF    THE     EYELIDS    AND    ORBIT.  89 

the  upper  lid  especially,  to  become  everted.  If  this 
happens  under  the  observation  of  the  surgeon,  the 
eversion,  of  course,  is  corrected  at  once  and  without 
difficulty.  If,  however,  it  occurs  under  other  circum- 
stances, and  if,  so  occurring,  the  displacement  of  the 
lid  is  allowed  to  rem  am  for  several  days,  the  correction 
of  the  fault  is  no  longer  an  easy  matter.  In  fact,  a 
condition  comparable  to  paraphimosis  has  been  brought 
about,  and  the  everted  conjunctiva  is  now  congested 
and  greatly  swollen,  as  a  consequence  of  the  strangula- 
tion produced  by  the  action  of  the  distorted  orbicularis 
— a  typical  spasmodic  ectropion  has,  indeed,  already 
become  established.  Now,  it  the  lid  is  returned  to 
its  normal  position,  it  refuses  to  stay  there.  The 
faulty  position  has  become,  as  it  were,  the  "natural" 
position,  and  so  it  will  ever  remain,  unless  proper 
measures  are  taken  to  remedy  the  defect.  Briefly  told, 
this  is  the  usual  history  of  the  development  of  spas- 
modic ectropion. 

Cicatricial  or  organic  ectropion  is  commonly  of  trau- 
matic origin,  though  it  may  result  from  any  lesion 
which  leads  to  destruction  of  the  external  integument 
of  the  lid  or  of  the  neighboring  parts.  Burns,  whether 
from  hot  substances  or  caustic  agents,  lacerated  wounds, 
malignant  growths,  lupus,  and  caries  of  the  bones 
forming  the  border  of  the  orbit,  are  some  of  the  con- 
ditions apt  to  produce  it.  The  distortion  and  dis- 
placement of  the  lid  occurring  in  this  form  of  ectropion 
are  often  excessive  (Fig.  29);  nevertheless,  the  repulsive 
appearance  characteristic  of  spasmodic  ectropion  is 
seldom  present. 

The  incomplete  eversion  of  the  low^er  lid  caused  by 
eczema  of  the  lid  and  cheek  is  a  not  unusual  complica- 
tion of  disease  of  the  lacrimal  apparatus — of  any  con- 


90 


PREVALENT    DISEASES    OF    THE     EVE. 


dition,  in  fact,  whether  displacement  or  occlusion  of 
the  punctum,  or  stricture  of  the  canaliculus  or  lacrimal 
duct,  which  may  give  rise  to  epiphora,  the  overflow 
of  tears  and  mucus  being  the  exciting  and  continuing 


I 


Fig.  29. — Cicatricial    ectropion    following    bum    by    molten    lead    (Haab). 


Fig.  30.— Ectropion  of  the  lower  lid  due  to  facial  paralysis  (Haab). 


cause  of  the  eczema,  which,  through  the  resulting  skin 
contraction,  drags  the  lid  from  its  normal  position. 
In  this  way,  too,  senile  ectropion  and  the  ectropion 
of  facial  paralysis  (Fig.  30)  are  often  greatly  aggravated; 
for  the  malposition  of  the  lower  punctum  present  in 


DISEASES    OF    THE     EYELIDS    AND    ORBIT. 


91 


both  of  these  conditions  usually  gives  rise  to  epiphora, 
and,  sooner  or  later,  a  dermatitis  of  the  lid  and  cheek, 
develops. 

A  more  marked  type  of  ectropion  of  the  lower  lid, 
attended  by  considerable  elongation  of  the  lid-margin, 
is  met  with  in  certain  cases  of  chronic  inflammation 
of  the  lids  and  conjunctiva  (Fig.  31).      Its  occurrence  is 


Fig.  31. — Ectropion  of  the  lower  lids    (de  Schweinitz  and    Randall). 


due  measurably  to  the  hypertrophied  condition  of  the 
palpebral  conjunctiva;  but  it  seems  probable  that  other 
factors,  such  as  an  ill-shaped  tarsus  or  a  badly  disposed 
orbicularis  muscle,  have  to  do  with  its  development 
(Fig.  32). 

Treatment. — The  slighter  degrees  of  ectropion  of 
the  low^er  lid,  such  as  occur  in  facial  paralysis  or  from 
senile    atrophy    or   eczema    of  the    cheek,    are   chiefly 


92 


PRKVALKNT    DISEASES    OF    THE     EYE. 


annoying  because  of  the  epiphora  to  which  they  give 
rise.  They  require,  therefore,  no  treatment  beyond 
the  sHtting  cf  the  lower  canahculus.  This  simple 
procedure  not  only  does  away  with  the  epiphora,  but, 
by  preventing  the  excoriation  of  the  skin  by  the  over- 
flowing tears,  not  infrequently  materially  lessens  the 
malposition  ot  the  lid. 

In  spasmodic  ectropion,  of  not  too  long  duration,  it 
is  often  possible  to  effect  a  cure  by  replacing  the  everted 


Fig.  32. — The  orbicularis  muscle  and  the  internal  palpebral  ligament 
(Nunneley).  The  palpebral  ligament  is  seen  at  a;  b  and  d  indicate  the 
palpebral  and  orbital  portions  of  the  orbicularis  muscle. 


lid  and  applying  a  compress  bandage.  After  this  has 
been  worn  for  two  or  three  days  the  tendency  of  the 
lid  to  become  everted  will  have  been  overcome.  When 
this  plan  fails,  the  procedure  suggested  by  Snellen 
should  be  resorted  to,  and  will  usually  be  found  effica- 
cious, unless  the  condition  has  lasted  so  long  that  the 
lid-margin  has  become  considerably  elongated.  The 
steps  of  Snellen's  operation,  which  is  applicable  to 
either  lid,  are  as  follows:  A  curved  needle  is  attached 
to   each   end   of  a   silk   thread,  and   both    needles  are 


DISEASES    OF    THE     EYELIDS    AND    ORBIT.  93 

passed,  from  within  outward,  through  the  whole  thick- 
ness of  the  lid.  The  points  of  entrance  should  be  5 
or  6  mm.  apart,  and  at  such  a  distance  from  the  border 
of  the  lid  that  the  needles  shall  pass  through  the  convex 
margin  of  the  tarsus.  The  points  of  exit  should  be 
about  a  centimeter  apart  and  two  centimeters  from 
the  lid-margin.  Sufficient  traction  is  now  made  upon 
the  thread  to  cause  the  lid  to  assume  its  proper  position, 
and  the  two  ends  are  then  tied  rather  tightly  over  a  piece 
of  small  rubber  tubing  or  a  roll  of  adhesive  plaster, 
which  prevents  the  thread  cutting  into  the  skin.  To 
effect  the  desired  result  two,  or  possibly  three,  threads 
may  sometimes  be  required.  A  light  bandage  should 
be  worn  for  several  days,  and  on  the  fourth  day  the 
stitches  should  be  removed. 

To  facilitate  the  replacement  of  the  lid,  excision  of  a 
portion  of  the  congested  and  swollen  palpebral  con- 
junctiva is  recommended;  but  the  end  in  view,  it 
would  seem,  might  be  attained  as  well  through  the 
markedly  astringent  action  of  adrenalin. 

When  ectropion  is  attended  by  considerable  elon- 
gation of  the  lid-border,  a  shortening  of  the  lid  be- 
comes an  essential  part  of  any  operation  undertaken 
for  the  correction  of  the  deformity.  This  was  accom- 
plished at  one  time  by  excising  a  wedge-shaped  piece 
from  the  center  of  the  lid,  but  a  better  procedure, 
and  the  one  now  usually  employed,  is  to  remove  the 
piece  at  the  outer  canthus,  as  suggested  by  von  Ammon. 
The  amount  of  shortening  required  will,  of  course, 
determine  the  size  of  the  wedge  to  be  removed.  The 
edges  of  the  incision  (Fig.  ^^,  A)  should  be  brought 
together  accurately  by  three  or  four  silk  sutures,  or 
by  a  harelip  pin,  as  shown  in  Fig.  33,  B. 

The   form   of  ectropion   most   difficult  to  correct  is 


94 


PREVALFNT    DISKASES    OF    THE     EYE. 


that  which  is  produced  by  the  contraction  of  scar- 
tissue,  and  innumerable  ingenious  operations  have 
been  contrived  for  this  purpose.  In  cicatricial  ectro- 
pion the  lid,  besides  being  everted,  usually  is  elongated 
and  dragged  away  from  its  proper  position.  It  may 
be  also  so  immovably  fixed  in  this  new  position  that 
closure  of  the  eye  is  quite  impossible. 

The  first  step  in  every  operation  for  the  correction 
of  this  variety  of  ectropion  is  the  freeing  of  the  lid 
from  its  attachments,  so  that  it  may  be  brought  into 
normal  relation  with  the  eye  and  with  the  fellow-lid. 
The    completion    of  this    step    usually    leaves,    in    the 


A  B 

Fig.  ^2- — Von  Amnion's  operation  for  shortening  the  lid. 

neighborhood  of  the  orbital  margin,  a  more  or  less 
extensive  area  denuded  of  integument,  and  the  filling 
of  this  gap  w^ith  skin,  which  is  necessary  to  prevent 
a  re-displacement  of  the  lid,  constitutes  the  second 
and  final  step  of  the  operation.  Formerly  this  was 
accomplished  by  some  form  of  plastic  operation,  usu- 
ally by  the  transplantation  of  flaps  of  skin  from  the 
neighboring  parts — the  forehead,  the  temple,  or  the 
cheek.  There  were,  however,  many  difficulties  and 
disadvantages  connected  with  such  operative  proced- 
ures, and  of  late  thev  have  been  in  large  measure  aban- 
doned, and  have  been  supplanted  by  the  modern  meth- 
ods of  skin-grafting  de^"ised  by  Wolfe  and  Thiersch. 


DISEASES    OF    THE    EYELIDS    AND    ORBIT. 


95 


When  the  ectropion  involves  the  lower  lid  its  re- 
placement, which  usually  includes  a  shortening  of 
the  lid-border,  is  commonly  effected  by  the  operation 
proposed  by  Arlt.  As  represented  in  Fig.  34,  A,  two 
converging  incisions,  a  b,  b  d,  are  made  through  the 
whole  thickness  ot  the  skin,  or  through  the  scar-tissue 
which  has  taken  its  place.  The  included  integument 
is  then  dissected  up  until  the  lid  is  free,  and  can  be 
restored  to  its  normal  position.  Next,  the  lid-border 
is  shortened  at  the  outer  canthus,  in  the  manner  already 

A  B 


Fig.    34. — A,   Arlt's   operation   for   cicatricial   ectropion   of  lower  lid;    B, 

final  stage. 

described.  An  effort  is  then  made,  by  undermining 
the  margins  of  the  incision,  a  g  d  (Fig.  34,  B),  to 
close  the  V-shaped  gap,  the  edges  being  brought  to- 
gether by  harelip  pins.  If  this  cannot  be  done  without 
undue  traction,  or  if  after  it  is  accomplished  a  gap  is 
left  above  wdiich  cannot  be  closed  except  by  such 
tension  upon  the  flap,  a  b  d,  as  might  result  ultimately 
in  a  recurrence  of  the  ectropion,  resort  should  be  had 
to  skin-grafts  with  which  to  fill  in  any  existing  gaps. 
Hotz,  who  has  given  special  attention  to  operations 
upon  the  lids,  recommends  that  for  this  purpose  grafts 


96  PREVALENT    DISEASES    OF    THE     EYE. 

obtained  by  the  Wolfe  method  should  be  employed. 
The  grafts,  which  include  the  whole  thickness  of  the 
skin,  but  which  should  be  freed  carefully  from  any 
underlying  fat,  may  be  obtained  most  advantageously 
from  the  inside  of  the  arm  or  forearm.  They  should 
be  shaped  to  fit  accurately  the  space  into  which  they 
are  to  be  inserted,  and  as  outlined  upon  the  skin  of 
the  arm  should  be  about  one-third  larger  than  this 
space,  to  allow  for  the  usual  shrinkage.  No  sutures 
are  required  to  maintain  them  in  position;  but,  after 
they  have  been  adjusted  carefully,  they  should  be 
covered  with  several  layers  of  silver-foil.  Over  this 
a  pad  of  sterile  gauze  and  absorbent  cotton,  of  suffi- 
cient thickness  to  afford  equable  support,  is  placed, 
and  is  kept  in  position  by  a  light  bandage  or  by  sev- 
eral strips  of  rubber  adhesive  plaster.  Owing  to  the 
overflow  of  the  secretions  from  the  eve,  it  is  usually 
necessary  to  change  the  dressings  on  the  third  or 
fourth  day;  otherwise,  it  would  be  advantageous 
to  allow^  them  to  remain  for  ten  or  twelve  davs. 

The  use  of  silver-foil  as  a  surgical  dressing,  first  sug- 
gested by  Dr.  Wm.  S.  Halsted,  has  been  a  matter  of 
routine  for  some  years  in  the  Johns  Hopkins  Hospital. 
All  fresh  wounds,  both  closed  and  open,  are  invariablv 
dressed  with  it,  and  as  a  covering  for  the  moist  blood- 
clot  and  for  skin  grafts  it  has  been  found  especially 
valuable.  Dr.  Halsted  advises  that  it  should  be 
"laid  on  without  stint,  at  least  three  or  four  lavers 
thick,  and  should  be  protected  from  the  outer  (gauze) 
dressing  by  two   or  three    layers    of    the  foil-paper." 

To  maintain  the  replaced  lid  in  its  proper  position 
and  to  guard  against  a  recurrence  of  the  ectropion, 
it  is  usual,  before  inserting  the  grafts,  to  unite  the 
margins  of  the  upper  and  lower  lids  bv  three  sutures, 


DISEASES    OF    THE    EYELIDS    A^T>    ORBIT,  gj 

which,  if  deemed  necessary,  may  be  left  in  position 
for  several  weeks. 

In  dealing  with  ectropion  of  the  upper  lid,  owing 
measurably  to  the  presence  of  the  eyebrow,  the 
V-shaped  incision  of  Arlt  does  not  yield  satisfactory 
results.  The  method  of  procedure  to  be  adopted  for 
the  correction  of  this  defect  will  vary  necessarily  with 
the  conditions  to  be  met;  but,  in  general,  it  will  consist 
of  a  freeing  of  the  retracted  and  everted  upper  lid,  so 
that  it  can  be  brought  into  proper  relation  with  the 
eye  and  with  the  fellow-lid  (to  which  it  should  be 
attached  by  sutures,  as  in  the  previously  described 
operation),  and  the  filling  of  the  resulting  gap  by 
Wolfe  or  Thiersch  grafts.  The  Thiersch  grafts  afford 
a  thinner  and  more  flexible  tissue,  and  for  this  reason 
are  preferable  if  they  are  to  form  a  part  of  the  lid 
proper  (Hotz);  but,  owing  to  the  marked  shnnkage 
which  they  undergo,  a  recurrence  of  the  ectropion  is 
liable  to  occur  if  they  are  depended  upon  to  fill  in 
gaps  of  considerable  size.  A  combination  of  the  two 
methods,  therefore,  may  be  employed  advantageously 
when  this  condition  has  to  be  met — Wolfe  grafts  being 
used  to  fill  large  gaps  upon  the  temple  or  above  the 
brow;  Thiersch  grafts,  to  build  up  the  lid  itself. 

The  Thiersch  grafts,  which  consist  only  of  the 
epidermis  and  the  very  superficial  layers  of  the  dermis, 
carefully  shaved  off  with  a  razor  or  other  keen-edged 
blade,  may  be  employed  to  excellent  purpose  to  pre- 
vent the  development  of  ectropion,  since  they  can  be 
"planted"  upon  granulating  surfaces  as  well  as  upon 
fresh  wounds.  For  this  reason,  too,  it  is  possible  to 
apply  supplementary  grafts,  should  any  of  those  ap- 
plied at  a   previous  operation  fail  to  "take." 

Sepsis  should  be  carefully  guarded  against  in  skin- 
7 


98  PREVALENT    DISEASES    OF    THE    EYE. 

grafting.  The  surface  from  which  the  graft  is  to  be 
taken,  as  well  as  that  to  which  it  is  to  be  transferred, 
should  be  rendered  as  nearly  as  possible  aseptic,  and 
all  dressings  employed,  including,  of  course,  the  silver- 
leaf,  should  be  sterile.  For  this  purpose  sublimate 
solutions  are  used  more  freely  in  the  surgical  service 
of  the  Johns  Hopkins  Hospital  than  was  at  one  time 
thought  advisable. 

Ptosis,  a  drooping  of  the  upper  lid  with  inability  to 
elevate  it,  occurs  as  a  congenital  and  as  an  acquired 
condition.  The  fault  is  usually  in  the  levator  muscle, 
though  exceptionally  the  defect  may  be  due  to  increased 
weight  of  the  lid  from  inflammatory  hypertrophy  or 
other  cause.  Acquired  ptosis  is  commonly  a  result  of 
paralysis  of  the  third  nerve,  a  twig  from  which  supplies 
the  levator  muscle,  and  is  very  often  dependent  upon 
syphilis.  When  this  is  the  case,  the  other  ocular 
muscles  supplied  by  the  third  nerve  are  usually  in- 
volved, and,  besides  drooping  of  the  lid,  we  have 
divergent  squint,  inability  to  turn  the  eye  inward,  up- 
ward, or  downward,  mydriasis,  and  loss  of  accommoda- 
tive power.  Exceptionally  only  that  branch  of  the 
third  nerve  which  supplies  the  levator  muscle  is  af- 
fected. Such  a  condition  may  be  caused  by  central 
disease,  or  it  may  occur  as  a  result  of  traumatism  or 
from  pathological  processes  in  the  orbit. 

Congenital  ptosis,  which  is  commonly  bilateral — 
acquired  ptosis  being  more  often  monolateral — is  not 
infrequentlv  an  inherited  condition.  It  is  caused  by 
faulty  innervation,  or  by  imperfect  development  or 
actual  absence,  of  the  elevator  muscle  of  the  lid.  The 
subjects  of  this  defect  acquire  the  habit  of  employing 
the  occipitofrontalis  muscle  to  lift  the  lids,  so  that 
the  eyebrows  are  unduly  elevated.     They  are  inclined 


DISEASES    OF    THE     EYELIDS    AND    ORBIT. 


99 


also  to  throw  the  head  backward,  since  this  makes  it 
easier  for  them  to  see  straight  forward,  as  the  upper 
hd,  under  such  circumstances,  need  not  be  elevated 
as  much  as  would  otherwise  be  necessary.  They 
present,  therefore,  an  odd  and  characteristic  appear- 
ance, which  is  well  shown  in  the  accompanying  illustra- 
tion (Fig.  35).  The  appearance  exhibited  in  acquired 
monolateral  ptosis^  if  it  is  complete — for  varying  de- 
grees of   both  congenital  and  acquired  ptosis  are  met 


Fig.  35. — Congenital  ptosis  (T.  C.  Evans). 


with — is  exactly  that  of  a  person  who,  keeping  one 
eye  open,  succeeds  in  closing  the  other  without  ap- 
parent muscular  effort  (Fig.  36). 

Treatment. — In  congenital  ptosis  only  operative 
treatment  is  of  avail;  on  the  other  hand,  in  acquired 
ptosis  operative  measures  should  be  resorted  to  only 
when  all  other  means  have  been  tried,  and  have  proved 
ineffectual.  As  a  rule,  if  the  condition  is  not  ot  long 
standing,  the  prognosis  in  acquired  ptosis  is  favorable. 


100  PREVALENT    DISEASES    OF    THE     EYE. 

This  is  true,  especially,  of  the  many  cases  which  are 
of  luetic  origin.  In  these  cases,  as  well  as  in  those 
dependent  upon  rheumatism,  potassium  iodid,  in 
liberal  doses,  is  perhaps  the  most  valuable  remedy 
we  possess.  The  biniodid  of  mercury  is  another  valu- 
able remedy,  and  with  either  of  these  strychnin  may 
be   advantageously  combined.      Counter-irritation,  by 


Fig.  36. — Acquired  ptosis  with  cystic  tumor  of  orbit    (de  Schwcinitz  and 

Randall). 

means  of  blisters  applied  to  the  forehead  or  temples, 
at  times  seems  to  exert  a  good  effect.  I  have  not  much 
confidence  in  the  efficacy  of  galvanism  in  these  cases; 
but  some  authorities,  probably  with  larger  experience 
in  its  use,  hold  it  in  higher  esteem.  When  constitu- 
tional treatment  has  been  given  a  thorough  trial  without 
effect,  and  only  then,  resort  should  be  had  to  one  of 
the  operative  measures  presently  to  be  described. 


DISEASES    OF    THE    EYELIDS    AND    ORBIT.  101 

For  the  correction,  more  especially,  of  congenital 
ptosis,  innumerable  operative  procedures,  and  num- 
berless modifications  of  previously  suggested  operations, 
have  been  proposed.  When  so  many  plans  are  sug- 
gested to  meet  a  given  condition  the  inference  is  war- 
ranted that  no  one  ot  them  is  entirely  satisfactory, 
and  this  is  certainly  true  of  the  many  operations  de- 
vised for  the  correction  of  ptosis. 

All  of  these  procedures,  with  one  or  two  unimportant 
exceptions,  aim  either  to  shorten  the  eyelid,  so  that 
it  shall  not  interfere  so  greatly  with  vision,  or  to  render 
more  effective  the  vicarious  action  of  the  occipito- 
frontalis  muscle  in  its  endeavor  to  take  the  place  of 
the  incapacitated  levator  palpebrae. 

The  objection  to  those  operations  which  aim  at 
shortenmg  the  lid  is  that  in  ptosis,  as  a  rule,  the  lid 
is  not  elongated.  Indeed,  in  congenital  ptosis,  perhaps 
in  consequence  of  the  long-continued  action  of  the 
occipitofrontalis,  it  not  infrequently  appears  to  be 
preternaturally  short.  If  under  such  circumstances  it 
is  shortened  still  more,  sufficiently  to  raise  it  above  the 
level  of  the  pupil,  there  is  great  danger  of  producing 
the  condition  known  as  lagophthalmos — inability  to 
close  the  eye  or,  at  all  events,  to  keep  it  closed  without 
actual  effort — a  condition  which,  especially  through 
lack  of  protection  of  the  cornea  during  sleep,  may  lead 
to  serious  consequences.  If,  however,  there  is  actual 
elongation  of  the  lid,  and  sometimes  when  it  is  only 
of  the  usual  length,  as  is  more  apt  to  be  the  case  m 
acquired  ptosis,  much  relief  may  be  afforded  by  an 
operation  which  will  shorten  it  to  the  degree  required. 

The  shortcoming  in  those  procedures  which  undertake 
to  render  the  action  of  the  occipitofrontalis  more  effec- 
tive is   that,   notwithstanding  our   best   efforts   in   this 


102  PREVALENT    DISEASES    OF    THE     EYE. 

direction,  the  part  of  levator  of  the  hd  is  phiyed  by 
this  muscle  in  rather  lame  fashion. 

Of  the  various  operations  proposed  for  shortening 
the  lid,  the  most  rational  is  the  procedure  first  sug- 
gested by  Bowman,  in  1859 — the  removal  of  a  portion 
of  the  tarsal  cartilage.*  The  credit  of  originating  this 
operation  is  commonly  given  to  Gillet  de  Grandmont; 
but  the  procedure  which  he  described  in  i89i,f  though 
differing  in  minor  details,  is  essentially  that  which 
Bowman  employed  thirty-two  years  before.  Quite  re- 
cently this  operation  has  been  somewhat  modified  and 
improved  upon  by  Gruening,  who  speaks  enthusias- 
tically of  the  excellent  results  which  it  has  afforded 
him.  His  modification  consists  chiefly  in  the  method 
of  introducing  the  sutures  which  are  employed  to  bring 
together  the  edges  of  the  divided  cartilage. 

Like  de  Grandmont,  Gruening  makes  an  incision, 
corresponding  in  length  with  the  tarsus,  through  the 
external  integument  of  the  lid,  parallel  with  and  about 
3  mm.  from  its  free  border,  and,  after  dissecting  back 
the  skin  and  orbicularis  muscle  until  the  whole  tarsal 
cartilage  is  exposed,  removes  a  semilunar  piece  of  the 
cartilage  and  the  subjacent  conjunctiva  by  two  incisions, 
one  straight  and  parallel  with  the  lid-margin,  the  other 
curvilinear,  with  its  convexity  upward,  and  joining  the 
extremities  of  the  first  incision.  The  breadth  of  the 
piece  of  cartilage  to  be  removed  is  determined  by  the 
effect  desired.  If  a  shortening  of  the  lid  amounting  to  6 
mm.  is  desired,  the  excised  piece  should  have  a  breadth 
in  the  center  of  6  mm.  and  at  each  extremity  of  2  mm. 
The  upper  border  of  the  cartilage  Gruening,  following 

*  "Royal  London  Ophthalmic  Hospital  Reports,"  Vol.  I,  p.  34. 
t  "Journ.  de  Med.  de  Paris,"   1891,  p.  296. 


DISEASES    OF    THE     EYELIDS    AND    ORBIT. 


103 


the  example  of  Heisrath,*  leaves  intact,  so  that  the 
cartilage  is  actually  cut  in  two,  a  crescentic  piece  being 
left  above,  a  long  strip,  with  nearly  parallel  sides,  below 

(Fig-  31)- 

In  de  Grandmont's  operation  the  deep  parts  of  the 
wound  are  united  by  three  catgut  sutures,  which  are 
left  to  undergo  absorption,  the  skin  being  closed  over 
them.  Gruening,  on  the  other  hand,  brings  the  lips 
of  the  cartilage  wound  into  apposition  by  means  of 
three    double-armed    silk    threads.     The    needles    at- 


i  Hii.liai  J. 


I'ig-  37- — Gruening's    modification  of    the    Bowman-deGrandmont    opera- 
tion for  ptosis. 


tached  to  each  of  these  are  passed  first  through  the 
lower  edge  of  the  upper,  crescentic  portion  of  the 
divided  cartilage,  then  downward  through  the  lid 
structures,  as  shown  in  the  illustration,  and,  finally, 
are  brought  out  upon  the  free  border  of  the  lid,  behind 
the  lashes,  where  each  pair  of  threads  is  tied,  after 
having  been  drawn  tightly  enough  to  close  the  cartilage 
wound.  The  skin  wound  may  be  closed  by  several 
superficial    sutures,    though    this    is    hardly   necessary. 

*  "Berliner  klin.  Wochenschrift,"  1891,  p. 58. 


I04 


PREVALENT    DISEASES    OF    THE    EYE. 


The  deep  sutures  are  removed  on  the  fifth  day.  With 
proper  antiseptic  precaution  these  sutures  are  not 
hkely  to  excite  undue  inflammatory  reaction,  and,  on 
the  whole,  are  to  be  preferred  to  the  buried  stitches 
of  de  Grandmont. 

Of  the  operations  designed  to  render  more  effective 
the  action  of  the  occipitofrontahs  in  hfting  the  hd,  that 
contrived  by  Panas  affords  the  best  results.  By  refer- 
ence to  the  illustrations  (Figs.  38  and  39)  the  steps  of 
this  operation  are  made  easily  comprehensible.  A 
horizontal  incision,  2  cm.   long,  is  made  through  the 


Fig.  38. — Panas's  operation  for  ptosis.    Fig.  39. — Panas's  operation  concluded. 


skin  and  orbicularis  muscle  a  short  distance  below  the 
upper  margin  of  the  orbit.  From  near  each  extremity 
of  this  incision  two  vertical  incisions  are  carried  down- 
ward to  a  point  2  or  3  mm.  below  the  upper  margin 
of  the  tarsal  cartilage,  where  each  incision  is  continued 
horizontally,  as  shown  in  the  illustration.  The  flap 
of  skin  and  muscle  thus  formed  is  then  dissected  up 
from  the  underlying  fascia  and  cartilage.  Another 
incision,  3  cm.  long,  is  next  made  through  the  skin  and 
muscle  just  above,  and  following  the  curve  of,  the  eye- 
brow, and  the  bridge  of  skin  between  this  incision  and 


DISEASES    OF    THE    EYELIDS    AND    ORBIT.  I05 

the  lower  incision  is  undermined.  By  means  of  three 
sutures  introduced  near  its  upper  margin,  and  passed 
beneath  this  bridge  of  skin,  the  flap  is  now  drawn  up 
under  the  bridge,  and  attached  to  the  upper  edge  of 
the  incision  above  the  brow.  To  prevent  the  traction 
which  results  from  causing  eversion  of  the  lid-margin, 
two  lateral  sutures,  as  shown  in  the  illustration,  are 
passed  through  the  tarso-orbital  fascia  and  conjunctiva, 
without  including  the  skin,  and  are  carried  up  subcu- 
taneously  and  attached,  like  the  previously  mentioned 
sutures,  to  the  lip  of  the  upper  incision. 

The  effect  of  the  operation,  in  lifting  the  lid,  will 
depend  largely  upon  the  width  of  the  undermined 
bridge  of  skin,  or,  in  other  words,  upon  the  distance 
between  the  two  horizontal  incisions  If  this  is  too 
great,  the  effect  will  be  excessive;  if  not  great  enough, 
it  will  be  insufficient.  It  is  a  matter  of  importance, 
therefore,  taking  into  account  the  degree  of  ptosis  and 
the  redundancy  or  scantiness  of  the  integument  of  the 
lid,  to  determine  how  considerable  this  distance  shall  be. 
The  operation  being  completed,  the  wounds  should  be 
covered  with  silver-foil,  and  over  this  a  pad  of  sterilized 
gauze  should  be  applied;  and  on  the  fourth  or  fifth 
day  the  stitches  should  be  removed. 

Paralysis  of  the  facial  nerve,  a  condition  nearly 
always  unilateral,  affects  the  eye  through  loss  of  power 
of  the  orbicularis  muscle  (Fig.  40)  The  lids  do  not 
close  properly,  and  the  lower  lid  tends  to  sag,  so  that  the 
lacrimal  punctum  fails  to  maintain  its  normal  position 
w^th  reference  to  the  eyeball.  In  consequence  of  this, 
epiphora  is  commonly  present.  Partly  owing  to  the 
epiphora,  and  still  more  because  the  lids  do  not  afford 
the  usual  protection  to  the  eye,  conjunctivitis,  and  less 
frequently  keratitis,  may  develop.     When  the  paralysis 


io6 


PREVALENT    DISEASES    OF    THE     EVE. 


is  complete,  the  eye  cannot  be  closed,  and  when  an 
effort  is  made  to  close  it,  the  eyeball  is  turned  strongly 
upward  in  a  manner  which  is  quite  characteristic. 

The  lesion  causing  the  palsy  is  usually  peripheral, 
and  may  involve  the  nerve  during  its  course  through 
the  temporal  bone  or  after  its  emergence  from  the 
stylomastoid  foramen.  Disease  of  the  middle  ear  is 
probably  the  commonest  cause  of  facial  paralysis.     It 


Fig.   40. — Right-sided  facial  paralysis,  showing  inability  to  close  the  lids 
from  involvement  of  the  orbicularis  palpebrarum  (Ramsay). 


may    also    follow    surgical    operations    or    other    trau- 
matisms   involving   the    tympanum.      It    is    sometimes 
,  dependent   upon   syphilis,   and   it   may   be  brought  on 
^    by  exposure  to  draughts  or  to  cold.     It  is   also   met 
with  in  connection  with  hemiplegia,  and,  according  to 
the  location  of  the  intracranial  lesion,  ma\'  be  on  the 
same  side  as  the  hemiplegia  or  on  the  opposite  side. 
Treatment. — This  will  depend,  of  course,  upon  the 


DISEASES    OF    THE     EYELIDS    AND    ORBIT.  IO7 

cause  of  the  attack.  In  recent  cases  the  prognosis  usu- 
ally is  favorable.  As  a  matter  of  routine,  it  is  well  al- 
ways to  examine  the  ear,  unless  it  is  manifest  that 
the  lesion  is  located  elsewhere.  Potassium  iodid  in 
liberal  doses  is  indicated,  and  its  usefulness  is  by  no 
means  limited  to  the  cases  of  syphilitic  origin.  Strychnin 
also  is  useful,  and  some  authorities  place  reliance  in 
electricity.  Small  blisters,  applied  in  front  of  the 
auricle,  seem  at  times  to  be  of  benefit.  When  disease 
of  the  middle  ear  is  present,  its  treatment  is  of  the  first 
importance. 

If  keratitis  develops,  measures  should  be  taken  to 
insure  proper  protection  of  the  cornea  by  the  lids. 
This  is  especially  important  during  sleep,  as  more  pro- 
longed exposure  of  the  eye  is  then  apt  to  occur.  This 
may  be  accomplished  by  the  application  over  the  lids  of 
a  light  bandage,  or  a  gauze  compress,  held  in  place  by 
two  or  three  strips  of  rubber  adhesive  plaster. 

The  most  useful  application  for  the  keratitis  is  a 
collyrium  of  holocain  and  boracic  acid  (holocain  hydro- 
chlorate,  gr.  j;  acid,  boracic,  gr.  x;  aquae,  destil.,  5J), 
which  may  be  dropped  into  the  eye  three  to  five  times 
a  day.  When  only  conjunctivitis  is  present,  a  ten-  to 
fifteen-grain  solution  of  boracic  acid,  or  a  sublimate 
solution  (i  :  8000  to  i  :  12,000),  should  be  prescribed. 


DISEASES  OF  THE  ORBIT. 
Diseases  of  the  orbit  hardly  deserve  to  be  regarded 
as  among  the  more  prevalent  affections  of  the  eye. 
However,  it  will  not  be  out  of  place  to  treat  briefly  of  cel- 
lulitis of  the  orbit,  of  periostitis  and  caries  of  the  or- 
bital walls,  and  of  the  orbital  tumors  which  are  most 
frequently  encountered. 


io8 


PREVALENT    DISEASES    OF    THE     EYE. 


Cellulitis  of  the  orbit,  leading  usually  to  abscess, 
or  phlegmon  (Fig.  41),  occurs  as  an  acute  affection  and, 
less  frequently,  as  a  subacute  or  chronic  process.  It 
may  arise  from  a  variety  of  causes,  such  as  local  injuries 
of  various  sorts,  "cold,"  the  extension  of  inflammation 
from  the  integument  of  the  face,  as  in  facial  erysipelas, 
or  from  the  sinuses  accessory  to  the  orbit,  periostitis 
of  the  orbital  walls,  panophthalmitis,  and  meningitis. 
It  occurs  also  as  a  post-typhoidal  and  a  post-scarlatinal 
affection,  and  as  a  manifestation  of  a  general  pyemia. 

The  acute  form  of  the  disease  is  characterized  by 


iig.  41. — Orbital  abscess  (.Ramsay;. 


headache,  severe  pain  in  the  orbit,  increased  by  pressure 
upon  the  eve  or  by  an  attempt  to  rotate  it,  protrusion 
of  the  eveball,  with  limitation  of  its  movements,  marked 
injection  and  chemosis  of  the  conjunctiva,  and  redness 
and  brawny  swelling  of  the  lids.  It  is  commonly  at- 
tended also  by  evidences  of  constitutional  disturbance, 
such  as  elevation  of  temperature,  loss  of  appetite, 
sleeplessness,  etc.  In  the  chronic  type  of  the  affection 
all  the  symptoms  are  less  pronounced;  thev  are  also 
less  typical,  and  in  consequence  a  correct  diagnosis 
is  not  so  easily  made. 

The  prognosis  in  the  milder  cases,  which  mav  ter- 


DISEASES    OF    THE     EYELIDS    AND    ORBIT.  IO9 

minate  without  suppuration,  is  favorable.  But  in  the 
more  severe  cases,  especially  in  those  which  are  conse- 
quent upon  facial  erysipelas,  the  prognosis  is  grave; 
for  not  only  is  there  danger  of  loss  of  sight  from  involve- 
ment ot  the  optic  nerve,  or  from  necrosis  of  the  cornea 
or  the  supervention  of  panophthalmitis,  but  a  fatal 
result  may  ensue,  through  extension  of  the  suppurative 
process  to  the  brain  or  through  the  occurrence  of  a 
general  pyemia. 

Because  of  the  great  swelling  of  the  lids  and  the 
conjunctival  chemosis,  acute  cellulitis  of  the  orbit  may 
be  mistaken  for  gonorrheal  conjunctivitis  or  for  pan^ 
ophthalmitis.  However,  it  may  be  distinguished  from 
the  former  affection  by  the  existence  of  exophthalmos, 
by  limitation  of  the  movements  of  the  eye,  and  by 
the  absence  of  copious  purulent  discharge,  and  from 
the  latter,  by  the  fact  that  the  cornea  is  clear — not 
opaque  and  necrotic,  as  it  usually  is  in  panophthalmitis. 

Treatmejit. — This  should  be  both  local  and  constitu- 
tional. In  the  acute  form  of  the  disease  the  local  treat- 
ment should  consist  in  the  constant  application  of  a 
warm  anodyne  fomentation — the  lotion  of  opium  and 
boracic  acid,  applied  by  means  of  a  gauze  pad  covered 
with  rubber  protective,  as  previously  described  (ext. 
opii.,  gr.  x-xv;  acid,  boracic,  gr.  xl;  aq.  destil.,  5Jv) 
— and  an  early  incision,  to  afford  efficient  drainage. 

The  mcision,  which  it  may  be  necessary  to  extend 
deeply  into  the  orbit,  should  be  made  from  the  con- 
junctival cul-de-sac  or  through  the  lid,  as  may  seem 
to  be  indicated.  A  straight,  narrow  bistoury  should 
be  used,  and  the  blade  should  be  entered  flatwise  with 
reference  to  the  eyeball,  to  avoid  the  risk  of  wounding 
it.  It  is  well,  too,  to  bear  in  mind  that  if  the  incision 
Is  made  in  the  upper  nasal,  or  in  the  lower  nasal,  angle 


no  PREVALENT    DISEASES    OF    THE     EYE. 

of  the  orbit,  there  is  danger  that  one  or  the  other  of 
the  obHque  muscles  may  be  divided.  In  severe  cases, 
especially  those  of  erysipelatous  origin,  it  may  be  neces- 
sary to  make  several  mcisions.  The  introduction  of 
an  iodoform-gauze  drain  is  indicated  when  the  sup- 
puration is  deeply  seated  or  when  the  external  wound 
shows  a  disposition  to  close.  Systematic  syringing  of 
the  pus  cavity  with  a  warm  antiseptic  solution  (a  satu- 
rated solution  of  boracic  acid,  a  one  per  cent,  solution 
of  carbolic  acid,  or  a  i  :  8000  to  i  :  4000  sublimate 
solution)  should  be  practised,  and,  if  the  discharge  is 
considerable,  should  be  repeated  two  or  three  times 
a  day. 

Should  panophthalmitis  develop  during  an  attack  of 
orbital  cellulitis,  enucleation  of  the  eye,  in  my  opinion, 
should  be  performed  without  unnecessary  delay. 
Resort  to  this  measure,  under  such  circumstances,  is 
commonly  condemned,  upon  the  ground  that  the 
danger  of  cerebral  infection  is  increased  through  the 
consequent  opening  of  the  lymph-channels  of  the  optic 
nerve;  but,  it  seems  to  me,  any  added  risk  from  this 
source  is  more  than  offset  by  the  greatly  improved 
drainage  of  the  orbit  afforded  by  the  removal  of  the 
eye,  besides  which  the  operation  may  be  counted  upon 
to  relieve  the  patient  of  much  suffering  and,  in  all 
probability,  to  considerably  curtail  the  duration  of  the 
orbital  inflammation.  The  possible  dependence  of  the 
cellulitis  upon  periostitis  or  caries  of  the  orbital  walls 
should  not  be  lost  sight  of. 

The  constitutional  treatment  of  the  acute  form  of 
the  disease  should  consist  in  the  administration  of  an 
energetic  mercurial  purgative,  to  be  followed  bv  liberal 
doses  (gr.  xx  every  two  hours)  of  sodium  pyrophosphate. 
Iron  and  quinin  may  also  be  called  for.  In  the  chronic 
form,  tonics  and  alteratives  are  indicated. 


DISEASES    OF    THE    EYELIDS    AND    ORBIT.  Ill 

Periostitis,  Caries,  and  Necrosis  of  the  Orbital 
Walls. — Periostitis  ot  the  walls  ot  the  orbit,  leading 
frequently  to  caries  and  not  rarely  to  necrosis,  is  met 
with  as  a  chronic  and  as  an  acute  affection.  Its  most 
common  causes  are  syphilis,  inherited  and  acquired, 
rheumatism,  scrofula,  local  injuries,  and  disease  of 
the  accessory  cavities. 

The  symptoms  of  acute  periostitis  resemble  those 
of  orbital  cellulitis,  to  which,  indeed,  it  not  infrequently 
gives  rise.  Deep-seated  pain,  increased  by  pressure 
upon  the  eyeball,  edema  of  the  lids,  conjunctival 
hyperemia,  limitation  of  the  movements  of  the  eye, 
attended,  perhaps,  by  diplopia,  and  more  or  less 
evident  exophthalmos,  are  the  usual  symptoms  when 
the  disease  occurs  in  the  deeper  parts  of  the  orbit. 
When  it  is  situated  nearer  the  orbital  margin,  localized 
tenderness,  manifested  upon  pressure  on  or  beneath 
the  border  of  the  orbit,  is  a  characteristic  symptom, 
and,  under  such  circumstances,  it  is  often  possible  to 
detect  the  thickening  of  the  periosteum. 

Suppuration  is  more  apt  to  occur  when  the  periostitis 
is  of  tuberculous  or  of  traumatic  origin,  or  when  it  is 
secondary  to  disease  of  the  neishboring-  cavities.  It  is 
least  apt  to  happen,  and  the  affection  is  more  prone 
to  be  chronic,  when  it  is  dependent  upon  rheumatism 
or  syphilis. 

When  the  inflammation  is  pronounced,  and  involves 
the  apex  of  the  orbit,  loss  of  sight  may  occur  through 
compression  of  the  optic  nerve.  Again,  if  caries  and 
necrosis  supervene,  especially  when  the  roof  of  the  orbit 
is  involved,  intracranial  complications  mav  result.  If 
suppuration  takes  place  in  the  cellular  tissue  of  the 
orbit,  any  of  the  untoward  consequences  which  have 
just  been  described  in  treating  of  this  condition  may 


112  PREVALENT    DISEASES    OF    THE     EYE. 

ensue.  Furthermore,  when  exit  has  been  given  to  the 
pus  the  discharge  is  apt  to  persist,  and  a  fistula  to 
become  estabHshed,  which  will  not  close  until  the 
disease  of  the  bone  has  been  overcome.  One  ot  the 
unpleasant  consequences  to  which  this  is  apt  to  give 
rise  is  a  permanent  distortion  of  the  lid,  usually  a  more 
or  less  pronounced  ectropion  (Fig.  42). 

Treatment. — This  will  depend,  of  course,  upon  the 
character  of  the  attack,  its  cause,  and  upon  the  extent 


Fig.  42. — Ectropion   of   upper   lid   from    caries   of   orbital    roof    (author's 

case). 


to  which  the  bone  has  become  involved.  The  salicy- 
lates and  potassium  iodid  are  indicated  when  the 
affection  is  of  rheumatic  origin,  and  the  latter,  in  com- 
bination, perhaps,  with  mercury,  when  it  is  dependent 
upon  constitutional  syphilis;  iodid  of  iron,  cod-liver 
oil,  and  the  hypophosphites  when  it  is  tuberculous. 

An  early  incision  is  called  for  when  suppuration 
supervenes,  to  be  followed  by  systematic  syringing  with 
an  antiseptic  solution;  and,  as  caries  is  usualh'  present 
under  such  circumstances,  treatment  directed  to  this 


DISEASES    OF    THE    EYELIDS    AND    ORBIT.  II3 

condition  should  be  instituted  when  the  acute  symp- 
toms have  subsided.  Careful  curetting  may  become 
necessary;  but  before  this  is  resorted  to,  or  as  sup- 
plementary to  it,  an  effort  should  be  made  to  remove 
any  dead  bone  which  may  be  present,  and  to  bring 
about  a  healthier  action  in  the  periosteum  and  in  the 
bone  itself,  by  the  use  of  hydrochloric  acid. 

If  the  carious  bone  is  so  situated  as  to  be  readily 
reached,  the  application  of  the  acid  may  be  made  most 
effectually  by  means  of  a  probe  armed  with  a  bit  of 
absorbent  cotton.  The  acid  (c.  p.)  should  be  diluted 
at  first  with  three  or  four  parts  of  water;  but,  if  well 
received,  the  strength  of  the  solution  may  be  gradually 
increased  to  equal  parts  of  each.  I  have  had  but  little 
experience  in  treating  caries  of  the  orbit  in  this  way; 
but  I  have  obtained  very  satisfactory  results  in  caries 
of  the  walls  of  the  auditory  canal  from  the  employment 
of  hydrochloric  acid  in  this  manner.  If  it  is  imprac- 
ticable to  make  the  application  in  this  direct  way,  the 
sinus  leading  to  the  carious  bone  may  be  syringed 
with  a  much  weaker  solution  of  the  acid — a  two  to  four 
per  cent,  solution  to  begin  with,  which  may  be  gradu- 
ally increased  to  twenty  or  twenty-five  per  cent,  if 
well  borne. 

Tumors  of  the  Orbit. — Tumors  of  many  kinds, 
malignant  as  well  as  benign,  are  met  with  in  the  orbit. 
They  may  have  their  starting-point  in  the  orbital  cel- 
lular tissue,  in  the  lacrimal  gland,  in  the  optic  nerve 
(Fig.  43),  in  the  bony  walls  which  surround  the  orbit; 
thev  may  invade  the  orbit  from  one  of  the  neighboring 
cavities,  or  they  may  begin  as  intraocular  growths. 

Benign  tumors  developing  in  the  orbit  may  cause 
serious  consequences  through  interference  with  vision. 
In  the  case  of  malignant  tumors  the  prognosis  is  most 


114 


PREVALENT    DISEASES    OF    THE     EYE. 


unfavorable,  not  only  as  to  sight,  but  as  to  life,  since 
they  are  prone  to  recur  even  after  most  thorough  re- 
moval, and,  sooner  or  later,  are  apt  to  involve  the 
brain  by  extension  along  the  optic  nerve  or  through 
the    roof  of  the  orbit. 

Among   the   benign   tumors   occurring   in   the   orbit 


¥>'. 


i 


Fig.  43. — Exophthalmos  lioin  filironia  of  the  optic  nerve.  The 
morbid  growth  in  this  case  extemled  into  the  optic  foramen,  at  which  point 
chlorid-of-zinc  paste  was  appHed  after  removal  of  the  eyeball  and  growth, 
without  exenteration.  Ten  years  later  there  had  been  no  recurrence 
(Buller). 

may  be  mentioned  lipoma,  fibroma,  dermoid,  sebaceous 
and  hydatid  cysts,  angioma,  osteoma,  and  gumma. 
The  malignant  growths  include  the  several  varieties 
of  sarcoma  (Fig.  44),  epithelioma,  usuallv  through  ex- 
tension from  the  lids  or  eyeball,  and  carcinoma,  com- 
monly having  its  starting-point  in  the  lacrimal  gland. 
Exophthalmos,  lateral  displacement  and  limitation  of 


DISEASES    OF    THE    EYELIDS    AND    ORBIT. 


115 


the  movements  of  the  eyeball,  diplopia,  impairment  oi 
vision  through  mvolvement  or  compression  of  the  optic 
nerve,  and  in  the  end  desiccation  and  necrosis  of  the 
cornea  from  lack  ofprotection,  are  commonly  observed 
when  the  growth  has  attained  a  considerable  size. 

In   endeavoring  to   determine   the   character  of  the 
growth,  palpation  is  at  times  of  much  assistance.     One 


Fig.  44. — Sarcoma  of  the  orbit  originating  in  the  tissues  of  the  apex  (BuUer). 


should  also  take  into  account  the  history  of  the  case, 
the  rapidity  with  which  the  tumor  has  developed,  the 
presence  or  absence  of  pain,  the  age  and  general  con- 
dition of  the  patient,  and  the  state  of  the  nose  and  of 
the  other  cavities  accessory  to  the  orbit.  The  possi- 
bility that  the  growth  may  be  of  syphilitic  origin  should 
not  be   lost  sight  of;    for  when  this    is    the   case    not 


Il6  PREVALENT    DISEASES    OF    THE     EYE. 

only  is  the  treatment  different,  but  the  prognosis  is 
decidedly  more  favorable. 

Treatment. — The  presence  of  an  orbital  tumor  having 
been  definitely  determined,  its  removal  is  commonly 
indicated.  There  are  exceptions,  however,  to  this 
rule.  For  example,  if  the  tumor  is  benign,  is  causing 
no  inconvenience,  is  not  increasing  in  size,  and  is  not 
readily  accessible,  it  is  permissible  to  postpone  opera- 
tive interference  as  long  as  these  conditions  maintain. 
Again,  when  it  is  evident  that  a  malignant  growth 
starting  in  the  orbit  has  already  invaded  the  neighboring 
cavities,  or  it  is  clear  that  such  a  growth  has  involved 
the  orbit  only  secondarily,  having  had  its  starting-point 
in  one  of  these  cavities,  since  no  operative  procedure, 
however  radical,  is  likely  to  be  of  avail,  either  in  re- 
lieving suffering  or  in  prolonging  the  life  of  the  patient, 
there  is  little  justification  for  undertaking    it. 

In  dealing  with  benign  tumors  it  is  usually  practica- 
ble, and  one  should  always  endeavor,  to  accomplish  their 
removal  without  sacrificing  the  e^'eball  or  in  any  way 
impairing  the  sight.  In  the  case  oi  malignant  growths, 
however,  the  preservation  ot  sight  becomes  a  matter  of 
secondary  importance,  and  not  only  the  eyeball  but  all  the 
contents  of  the  orbit  (exenteration  of  the  orbit),  and  in 
some  instances  the  lids  and  portions  of  the  orbital  walls, 
must  be  removed  (Fig.  45).  Cosmetically,  the  effect 
of  such  an  operation  is,  at  first,  rather  shocking;  but 
it  is  surprising  how  well  nature  copes  with  a  condition 
so  unpromising.  In  time  the  orbit  becom.es  greatly 
lessened  in  depth,  and  its  walls  become  lined  with  skin 
and  scar-tissue,  so  that  the  unsightliness  in  large  measure 
disappears.  (In  illustration  of  this,  compare  Figs.  45 
and  24.) 

Whenever  there   is   ground   for   suspecting  that   an 


DISEASES    OF    THE    EYELIDS    AND    ORBIT.  II7 

orbital  growth  may  be  of  syphilitic  origin,  mercury 
and  potassium  iodid  should  be  given  a  thorough  trial 
before  resort  is  had  to  operation. 

The  removal  of  intraorbital    growths,  it   should   be 
remarked,    ought    to    be    undertaken    only    by    those 


Fig.  45. — Exenteration  of  the  orbit,  with  removal  of  the  major  part 
of  the  lids,  for  epithelioma  of  the  lids  and  orbit  (author's  case;  photo- 
graph taken  two  weeks  after  operation). 


who,  in  addition  to  surgical  skill,  possess  thorough 
familiarity  with  the  anatomy  of  the  parts;  for,  even 
when  they  seem  to  be  superficial,  their  extirpation  may 
entail  invasion  of  the  deeper  parts  of  the  orbit,  and 
under  such  circumstances  irreparable  damage  to  sight 
may  result  from  awkward  manipulation. 


CHAPTER  lY. 

DISEASES  OF  THE  LACRIMAL  APPARATUS. 

In  treating  of  diseases  of  the  lacrimal  apparatus  it 
is  usual  to  consider,  first,  those  affections  which  have 
to  do  with  the  lacrimal  gland  and  its  ducts,  and,  second, 
those  which  pertain  to  the  drainage  apparatus,  includ- 
ing in  this  term  the  puncta,  the  canaliculi,  the  lacrimal 
sac,   and  the  nasal,  or  lacrimal,  duct.     As,   however, 


Fig.  46. — The  lacrimal  gland,  the  mouths  of  its  ducts  showing;  the 
meibomian  glands,  seen  upon  the  under  surface  of  the  lids,  and  the  lac- 
rimal puncta  (Nunneley). 

diseases  of  the  lacrimal  gland,  owing  to  the  protected 
position  of  the  gland  and  its  system  of  multiple  ducts 
(Fig.  46),  are  of  infrequent  occurrence,  they  will  be 
treated  of  very  briefly;  while,  on  the  other  hand,  affec- 
tions of  the  drainage  apparatus,  since  they  are  common, 
and,  as  a  rule,  may  be  successfully  treated  by  the  gen- 
eral practitioner,  will  be  considered  at  greater  length. 

118 


DISEASES    OF    THE     LACRIMAL    APPARATUS.  IIQ 

DISEASES  OF  THE  LACRIMAL  GLAND. 

Dacryoadenitis,  or  inflammation  of  the  lacrimal 
gland,  occurs  as  an  acute  and  as  a  chronic  affection. 
Both  varieties  are  rare,  though  it  seems  probable  that 
acute  inflammation  of  the  gland  is  sometimes  mis- 
taken for  cellulitis  of  the  orbit,  from  which  it  is  not 
always  easy  to  distinguish  it.  It  occurs  more  fre- 
quently in  children  than  in  adults  and  oftener  in  females 
than  in  males.  It  has  been  known  to  assume  an 
epidemic  character,  and  Galezowski  once  met  with  an 
unusual  number  of  cases  during  an  epidemic  of  mumps. 
Other  causes  to  which  it  has  been  ascribed  are  trau- 
matism, "cold,"  rheumatism,  gout,  tuberculosis,  syph- 
ilis, gonorrhea,  and  the  extension  of  inflammation  from 
the  conjunctiva  and  cornea.  It  is  usually  unilateral, 
but  not  infrequently  both  glands  are  involved. 

Acute  dacryoadenitis  gives  rise  to  severe  pain,  which 
may  be  accompanied  by  fever,  sleeplessness,  and  de- 
lirium. The  lids,  the  upper  lid  especially,  are  greatly 
swollen,  and  there  is  marked  chemosis  of  the  conjunc- 
tiva, the  general  appearance  of  the  eye  being  not  unlike 
that  which  characterizes  purulent  conjunctivitis  (S. 
C.  Ayres).  Through  the  enlargement  of  the  gland 
the  eyeball  may  be  displaced  and  its  movements  re- 
stricted. Palpation  of  the  gland,  because  of  its  ex- 
quisite sensitiveness  and  the  swelling  of  the  lid,  is 
difiicult,  and  eversion  of  the  lid,  to  permit  of  its  in- 
spection, is  impracticable.  Suppuration  may  supervene 
within  a  few  days,  the  pus  making  its  way  through 
the  integument  of  the  lid  or  into  the  conjunctival  cul- 
de-sac,  or  the  inflammation  may  subside  without  the 
formation  of  pus. 

In    chronic    dacryoadenitis   the    enlargement    of  the 


120  PREVALENT    DISEASES    OF    THE     EYE. 

gland  may  be  detected  by  palpation,  and  in  some 
instances  by  simple  inspection,  and  upon  everting  the 
lid  the  swollen  gland  may  be  brought  into  view  as 
a  red,  tongue-shaped,  nodular  mass  (Hirschberg). 
Though  the  gland  is  usually  sensitive  to  pressure,  there 
is  an  absence  of  the  pain,  edema  of  the  lids,  and  con- 
junctival chemosis  which  characterize  the  acute  variety 
of  the  disease.  Marked  displacement  of  the  eyeball, 
usually  downw^ard  and  inward,  may  occur,  and  this 
is  commonly  accompanied  by  diplopia. 

Treatment. — The  treatment  of  acute  dacryoadenitis, 
if  the  case  is  seen  in  its  incipiency,  should  consist  in 
the  local  abstraction  of  blood  by  leeches,  the  application 
of  ice-cloths  or,  if  more  acceptable  to  the  patient,  of 
a  lotion  of  lead  acetate  and  opium  (plumbi  acetatis, 
gr.  xv;  ext.  opii,  gr.  x-xv;  aq.  destil.,  oiv),  and  the 
administration  of  an  energetic  mercurial  purgative,  to 
be  followed  by.  liberal  doses  (twenty  grains  every  two 
hours)  of  sodium  pyrophosphate.  Should  these  meas- 
ures fail  to  cut  short  the  attack,  warm  fomentations, 
containing  opium  or  belladonna,  should  be  employed, 
and  as  soon  as  the  presence  of  pus  can  be  detected  it 
should  be  evacuated  by  an  incision  through  the  in- 
tegument of  the  lid  or  through  the  conjunctival  cul- 
de-sac,  as  may  seem  to  be  indicated. 

In  chronic  inflammation  of  the  gland  benefit  may 
be  expected  from  the  application  of  mercurial  or  com- 
pound iodin  ointment,  combined  with  the  administra- 
tion of  potassium  iodid  or  biniodid  of  mercury.  Should 
the  gland  become  so  enlarged  as  to  endanger  the 
integrity  of  the  eyeball,  its  extirpation  may  be  neces- 
sary. 

Fistula  of  the  lacrimal  gland  may  occur  as  a 
sequel  of  dacryoadenitis  or  may  be  of  traumatic  origin. 


DISEASES    OF    THE    LACRIMAL    APPARATUS. 


121 


In  rare  instances  it  has  been  observed  as  a  congenital 
defect.  The  fistulous  orifice  is  usually  situated  in  the 
upper  lid,  and  much  annoyance  results  from  the  tears 
which  constantly  flow  from  it. 

Treatmetjf. — It  is  not  easy  to  bring  about  a  healing 
of  the  fistula,  and  if  this  is  accomplished  it  is  at  the 
risk  of  precipitating  a  recurrence  of  the  dacryoadenitis. 
The  operative  procedure  which  has  proved  most  effec- 
tual is  that  suggested  by  Bowman.  Its  purpose  is  to 
convert  the  annoying,  external  cuta- 
neous fistula  into  one  opening  into  the 
conjunctival  sac,  and,  therefore,  caus- 
ing little  or  no  inconvenience.  A 
needle,  attached  to  a  silk  thread,  is 
passed  a  short  distance  into  the  fistula, 
and  is  then  made  to  transfix  the  lid, 
being  brought  out  upon  its  conjunc- 
tival surface.  A  second  needle,  upon 
the  other  end  of  the  thread,  is  next 
passed  through  the  lid,  close  to  the 
orifice  of  the  fistula.  The  two  ends  are 
then  tied  tightly,  and  the  thread  is  left 
to  cut  its  way  out.  To  promote  its 
closure,  the  edges  of  the  external  orifice 
of  the  fistula  are  freshened. 

Dacryops,  or  cyst  of  the  lacrimal  gland,  results 
from  occlusion  of  one  or  more  of  the  efferent  ducts 
of  the  gland  (Fig.  47).  It  has  also  been  met  with  as  a 
congenital  condition.  Upon  eversion  of  the  upper  lid 
the  cyst  may  be  observed  as  a  translucent,  at  times 
lobulated,  swelling.  Marked  distention  of  the  cyst  may 
occur  from  crying. 

Treatment. — This  consists  in  the  establishment  of 
a  permanent  opening  between  the  cyst  and  the  con- 


Fig.  47. — Three 
views  of  the  lacrimal 
gland,  the  efferent 
ducts  shown  in  one 
of  them  (Nunneley). 


122 


PREVALENT    DISEASES    OF    THE    EYE. 


junctival  sac.  It  may  be  accomplished  by  excising  a 
portion  of  the  cyst-wall  and  preventing  closure  of  the 
wound  by  the  repeated  introduction  of  a  probe,  or,  as 
suggested  by  von  Graefe,  by  passing  a  silk  thread 
through  the  wall  of  the  cyst,  tying  it  in  a  loop,  and 
leaving  it  to  cut  its  way  out. 

Dacryoliths,  chalky  concretions,  occasionally  form 
in  the  lacrimal  gland.     They  are  liable  to  cause  me- 


Fig.  48. — Enlargement  and  i)roIapse  of  the  palpebral  portion  of  the  lacrimal 
gland  in  an  eye  with  kerato-iritis  (de    Schweinitz). 


chanical  irritation,  and,  if  this  happens,  they  should 
be  removed  through  a  conjunctival  incision. 

Dislocation  of  the  lacrimal  gland,  sometimes 
described  as  hernia  or  prolapse  of  the  gland  (Fig.  48), 
has  been  met  with  as  a  spontaneous  condition,  and  as 
a  consequence  of  injury  involving  the  neighboring  parts. 

Treatment. — If  possible,  the  gland  should  be  restored 
to  its  normal  position,  and  a  compress  bandage  should 
be  applied,  and  worn  continuously  for  some  time  to 
prevent  a  redislocation.  If  this  is  impracticable,  re- 
moval of  the  gland  may  become  necessary. 


DISEASES    OF    THE    LACRIMAL    APPARATUS.         I23 

Hypertrophy  of  the  lacrimal  gland  occurs  more 
frequently  in  children  than  in  adults,  and  has  been 
known  to  be  of  congenital  origin.  The  gland  may 
become  so  greatly  enlarged  as  to  force  the  eyeball  from 
the  orbit,  and  destroy  sight  through  stretching  and 
compression  of  the  optic  nerve.  Cases  have  been  ob- 
served, however,  in  which  there  was  marked  displace- 
ment of  the   eye,  with   great  elongation   of  the  optic 


Fig.  4Q. — Hypertrophy    of  the  lacrimal    gland. 

nerve  and  external  ocular  muscles,  and  yet  fairly  good 
vision  and  ability  to  rotate  the  eye  were  retained. 

The  accompanying  illustration  (Fig.  49)  represents 
a  remarkable  case  of  this  character,  which  occurred 
in  the  practice  of  the  late  Prof.  Christopher  Johnston, 
of  Baltimore.  The  hypertrophied  gland,  which  was 
about  the  size  of  a  hen's  egg,  and  contained  numerous 
dacryoliths,  was  removed  by  Dr.  Johnston  through  an 
incision  made  parallel  with  the  orbital  margin.  The 
eye  subsequently  resumed  nearly  its  normal  position, 


124  PREVALENT    DISEASES    OF    THE     EYE. 

and  retained  vision  equal,  at  least,  to  counting 
fingers. 

Treatment. — If  the  enlargement  of  the  gland  is  not 
so  great  as  to  interfere  with  vision,  an  effort  should  be 
made,  by  the  application  of  mercurial  or  compound 
iodin  ointment  and  the  administration  of  potassium 
iodid,  to  arrest  the  hypertrophic  process.  The  possi- 
bility that  the  condition  may  be  of  syphilitic  origin 
should  be  borne  in  mind.  If,  however,  the  gland  is  so 
greatly  enlarged  as  to  endanger  the  integrity  of  the 
eye,  it  should  be  removed  without  unnecessary  delay. 

Removal  of  the  lacrimal  gland  may  be  accomplished 
by  either  of  two  procedures:  The  gland  may  be  exposed 
by  an  incision  through  the  integument  of  the  upper  lid 
parallel  with  the  orbital  margin,  drawn  out  with  a 
tenaculum,  and  separated  from  its  attachments  with 
a  knife  or  scissors.  The  objection  to  this  method  is 
that  it  involves  a  more  or  less  complete  division  of  the 
tendon  of  the  levator  palpebrae  superioris  muscle, 
which  may  result  in  the  production  of  ptosis. 

The  other,  and  probably  better,  plan,  suggested  by 
Velpeau,  is  to  divide  the  external  canthus,  evert  the 
upper  lid,  and  cut  down  upon  the  gland  from  the 
superior  conjunctival  cul-de-sac.  This  method  does 
not  endanger  the  integrity  of  the  levator  muscle,  and 
leaves  a  less  conspicuous  scar  than  the  first-described 
procedure. 

Atrophy  of  the  lacrimal  gland  has  been  observed 
as  one  of  the  late  consequences  of  trachomatous  con- 
junctivitis, in  the  condition  knowm  as  xerophthalmia. 
Arlt  has  described  a  case  of  this  character  in  which 
the  efferent  ducts  of  the  gland  were  obliterated,  and 
the  gland  itself  was  reduced  to  one-third  its  normal 
size.      Paralysis  of  the  trigeminus    may  result  in   abol- 


DISEASES    OF    THE    LACRIMAL    APPARATUS.         I25 

ishment  of  the  functional  activity  of  the  lacrimal 
gland. 

Tumors  of  the  lacrimal  gland  are  rare,  and,  not 
infrequently,  are  of  traumatic  origin.  They  are  usu- 
ally ot  slow  growth,  and  occur  oftenest  in  advanced 
life.  As  they  increase  in  size  they  interfere  with  the 
movements  of  the  eyeball,  giving  rise  to  diplopia. 
Later  they  produce  exophthalmos,  and,  eventually, 
may  not  only  destroy  sight  by  pressure  upon  the  optic 
nerve,  but  may  cause  death  by  extension  to  the  brain. 

The  following  varieties  of  tumors,  believed  to  have 
had  their  origin  in  the  lacrimal  gland,  have  been  ob- 
served: adenoma,  myxoma,  myxosarcoma,  lympho- 
sarcoma, spindle-cell  sarcoma,  epithelioma,  cylindroma, 
chloroma,  and  carcinoma. 

Treatment. — Early  and  complete  removal  of  the 
growth,  including,  of  course,  the  gland  itself,  is  indi- 
cated. Whether  this  can  be  accomplished  without 
sacrificing  the  eye,  will  depend  upon  the  size  of  the 
tumor  and  the  extent  to  which  it  has  invaded  the  deeper 
parts  of  the  orbit. 

DISEASES  OF  THE  DRAINAGE  APPARATUS. 

The  lacrimal  drainage  apparatus  (Fig.  ^o),  as  has 
been  said,  is  frequently  the  seat  of  pathological  changes. 
This  is  due  not  only  to  the  fact  that  the  mechanism  by 
which  the  tears  are  carried  from  the  conjunctival  sac  to 
the  nose  is  complex,  and  a  disarrangement  of  any  one 
of  its  parts  is  apt  to  disturb  the  normal  action  of  the 
whole,  but  to  the  further  fact  that  this  apparatus, 
while  an  appendage  of  the  eve,  is,  pathologically  con- 
sidered, a  part,  rather,  of  the  nasal  passages,  and  so 
prone  to  participate  in  the  many  maladies  to  which 
these  passages  are  liable. 


126 


PREVALENT    DISEASES    OF    THE     EYE. 


Whatever  may  be  the  nature  of  the  pathological 
changes  which  affect  the  drainage  apparatus,  and  wher- 
ever they  may  be  located,  a  common  symptom  charac- 
terizes them  all:  the  tears  are  no  longer  carried,  as  they 
should  be,  from  the  conjunctival  sac  to  the  nose,  and 
in  consequence  they  overflow  the  lids,  giving  rise  to  the 
annoying  condition  known  as  epiphora.  This  condition 
is  not  only,  in  itself,  very  annoying,  but  it  leads  to  chronic 


Internal  palpebral 
}\  ligament 

_  Opening  of  canalieu- 
tus  into  sac 
Constriction  marking 
beginning  oj  bony  caneil 
-  Middle  concha 


Inferior     termination 
of  na-iO'lacrimal 
duct 


.  Inferior  concha 


Fig.  50. — Section  showing  the  course  and  relations  of  the  lacrimal  sac  and 
nasal  duct  (Merkel). 


conjunctivitis,  to  blepharitis,  and,  not  infrequently,  to 
eczema  of  the  lids  and  cheek. 

Atresia  of  the  lacrimal  puncta  is  met  with  as  a 
congenital  and  as  an  acquired  anomaly.  Congenital 
atresia  of  the  puncta,  of  which  not  many  authentic 
cases  have  been  reported,  ma\'  affect  one  or  both  eyes, 
and  may  be  attended  by  absence  of  the  corresponding 
canaliculi.     I  have  encountered  one  case  of  this  char- 


DISEASES    OF    THE    LACRIMAL    APPARATUS.  12/ 

acter,  in  which,  however,  but  one  punctum,  with  its 
canahculus,  was  absent. 

As  an  acquired  condition,  complete  obHteration  of 
the  puncta  occurs  usually  as  a  result  of  destruction  of 
neighboring  parts,  such  as  may  happen  from  burns  of 
the  lids  by  molten  metal  or  lime.  It  has  been  known 
also  to  follow  the  cicatrization  of  a  smallpox  pustule 
and  of  a  chancre  of  the  lid.  A  superficial  occlusion, 
usually  of  the  lower  punctum,  which  is  easily  overcome, 
and  which  is  due  chiefly  to  desiccation  of  the  parts, 
is  often  observed  in  blepharitis  marginalis  complicated 
by  ectropion. 

Treatynent. — The  occlusion,  whether  congenital  or 
acquired,  may  commonly  be  overcome  without  much 
difficulty,   provided   the   canaliculus   is   not   absent   or 


Fig.  51. — Straight,  sharp-pointed  probe. 

has  not  been  obliterated.  A  slight  depression  usually 
marks  the  site  of  the  occluded  punctum,  and  at  this 
point  an  opening  may  be  drilled  into  the  canaliculus 
with  a  straight,  rather  sharp-pointed  probe,  such  as  is 
represented  in  Fig.  51.  After  this  has  been  accom- 
plished it  is  best,  as  a  rule,  to  slit  the  canaliculus; 
though  it  may  be  possible  to  prevent  a  recurrence  of 
the  occlusion  by  the  occasional  introduction  of  a  No.  2 
or  No.  3  probe.  If  the  canaliculus  as  well  as  the  punc- 
tum is  obliterated,  an  opening  must  be  made,  starting 
from  where  the  punctum  should  be,  and  follow^ing  the 
usual  direction  of  the  canaliculus,  into  the  lacrimal  sac. 
For  this  purpose  a  sharp-pointed  knife  is  required. 
We  shall  scarcely  succeed,  even  by  persistent  probing, 
in  keeping  open  a  considerable  part  of  this  artificial 
canaliculus;    but,  aided  by  the  action  of  the  tears,  we 


128  PREVALENT    DISEASES    OF    THE    EYE. 

may,  at  least,  he  able  to  establish  a  permanent  opening 
into  the  lacrimal  sac — as  I  succeeded  in  doing  in  the 
case  of  congenital  absence  of  the  punctum  and  canali- 
culus to  which  reference  has  been  made — and  so  get 
rid  of  the  epiphora  and  the  great  discomfort  to  which 
it  gives  rise. 

Malpositions  of  the  Puncta. — Normally  the  puncta 
lie  in  contact  with  the  eyeball,  and  this  position  is 
essential  to  the  proper  performance  of  their  office.  Mal- 
positions of  the  upper  puncta  are  not  common,  but 
misplacements  of  the  lower  puncta  are  more  frequently 
met  with,  and  usually  give  rise  to  greater  annoyance. 

Eversion  of  the  puncta  is  present  in  most  cases  of 
ectropion;  it  occurs  also  in  inflammatory  thickening 
of  the  lid-margin,  in  senile  relaxation  of  the  tissues  of 
the  lid,  and  in  facial  paralysis.  Inversion  of  the 
puncta,  which  is  less  frequently  encountered,  is  usually 
a  result  of  entropion.  Another  faulty  position  of  the 
puncta  results  from  the  eye  being  exceptionally  small 
or  being  deeply  set.  Under  such  circumstances  a 
triangular  space  is  present,  in  the  neighborhood  of 
the  inner  canthus,  between  the  lids  and  the  eye,  and 
in  consequence  the  puncta  and  the  eyeball  are  not  in 
apposition. 

Treatment. — The  efficient  remedy  for  all  malpositions 
of  the  puncta  is  division  of  the  corresponding  canalicu- 
lus. This  not  only  relieves  the  epiphora,  but  leads  to 
the  rapid  disappearance  of  the  conjunctivitis  and  the 
blepharitis  which  are  its  usual  accompaniments. 

Division  of  the  lower  canaliculus  (the  upper  canali- 
culus, in  my  experience,  seldom  needs  to  be  divided) 
is  accomplished  most  conveniently  with  the  straight, 
probe-pointed  canaliculus  knife  (Fig.  52),  a  modifica- 
tion of  the  beak-pointed  knife  of  Weber  (Fig.  53) .     Hav- 


DISEASES    OF    THE    LACRIMAL    APPARATUS. 


129 


ing  previously  dilated  the  punctum  and  canaliculus  by 
the  passage  of  a  small  probe,  the  operator,  standing  be- 
hind the  patient,  and  putting  the  lid  upon  the  stretch, 
introduces  vertically  into  the  punctum  the  probed  tip 
of  the  canaliculus  knife.  Then,  changing  the  direction 
of  the  knife,  he  passes  it  horizontally  along  the  canalic- 
ulus   until    its  progress  is  arrested  by  the  inner   wall 


Fig.  52. — Straight,  probe-pointed  canaliculus-knife. 


Fig.  53. — Weber's  beak-pointed  canaliculus-knife. 


Fig.  54. — Introduction  of  canaliculus-knife. 

of  the  lacrimal  sac  (Fig.  54).  This  point  having  been 
reached,  and  the  edge  of  the  knife  being  directed  upward 
and  slightly  backward,  the  lid  still  being  kept  well  upon 
the  stretch,  the  canaliculus  is  divided  by  simply  elevat- 
ing the  handle  of  the  knife.  If  the  operation  is  done 
as  a  step  preliminary  to  the  probing  of  the  lacrimal 
duct,  the  canaliculus  should  be  divided  well  up  to  its 
9 


130  PREVALENT    DISEASES    OF    THE     EYE. 

juncture  with  the  sac;    but  if  done  for  some  other  pur- 
pose, such  as  eversion  of  the  punctum,  it  may  not  be  ■ 
necessary  to  carry  the  division  quite  to  this  point. 

A  few  instillations  of  a  four  per  cent,  solution  of  cocain 
renders  the  operation  of  division  of  the  canaliculus 
almost  painless.  As  in  all  operations  upon  the  eye, 
the  instruments  used  should  be  sterilized  by  a  brief 
immersion  in  boiling  water;  after  which,  to  facilitate 
their  introduction,  it  is  well  to  dip  the  blade  of  the 
knife  and  the  probes  employed   into  sterilized  vaselin. 

The  edges  of  the  divided  canaliculus,  for  several 
days,  usually  show  a  disposition  to  grow  together,  and 
to  prevent  this  they  must  be  separated,  once  in  forty- 
eight  hours,  by  the  passage  of  a  greased  probe,  until 
this  disposition  is  overcome. 

Division  of  the  upper  canaliculus,  which,  as  has  been 
said,  is  seldom  called  for,  is  accomplished  bv  essen- 
tially the  same  procedure,  except  that  the  operator 
should  stand  or  sit  in  front  of  the  patient. 

Atresia  of  the  canaliculi  may  occur  as  a  con- 
genital defect,  in  association  with  absence  of  the  puncta, 
as  has  already  been  mentioned.  It  may  occur  also  as 
a  consequence  of  traumatism  or  of  an  ulcerative  process 
involving  the  region  of  the  inner  canthus.  Circum- 
scribed strictures  of  the  canaliculi  are  of  frequent  oc- 
currence, especially  in  connection  with  stenosis  of  the 
lacrimal  duct.  They  are  usually  located  near  the  point 
of  juncture  of  the  canaliculus  with  the  lacrimal  sac. 

Treatment. — When  the  canaliculi  are  completely 
obliterated,  their  restoration  by  operative  procedure 
is  impracticable.  It  may  be  possible,  however,  to  make 
an  opening  directly  into  the  lacrimal  sac,  and  by  re- 
peated probings  to  render  it  permanently  patulous. 
The  circumscribed  strictures  may  be  overcome  by  the 


DISEASES    OF    THE    LACRIMAL    APPARATUS.         I3I 

passage  of  a  small  lacrimal  probe  or  with  the  straight 
probe  represented  in  Fig.  51.  If,  however,  they  show 
a  disposition  to  recur,  the  canaliculus  should  be  slit. 

Dacryoliths,  small  concretions  composed  of  lime 
and  of  a  fungous  growth  (leptothrix),  occasionally  form 
in  the  canaliculi.  Their  presence  is  indicated  by  a 
circumscribed  swelling.  As  they  cause  more  or  less 
irritation,  and  give  rise  to  epiphora,  they  should  be 
removed  without  delay.  To  effect  their  removal,  slit- 
ting of  the  canaliculus  may  be  required. 

Polypi  sometimes  form  in  the  canaliculi,  and  may 
project  through  the  puncta.  Their  removal  may 
necessitate  division  of  the  canaliculus. 

Small  foreign  bodies,  eyelashes  especially,  at  times 
find  their  way  into  the  canaliculi,  where  they  .may 
remain  for  a  long  time,  causing  considerable  annoyance. 

Treatment. — If  they  project  through  the  puncta,  as 
they  usually  do,  they  may  be  seized  with  forceps  and 
easily  withdrawn;  otherwise,  division  of  the  canaliculus 
may  be  required  to  effect  their  removal. 

Dacryocystitis,  or  inflammation  of  the  lacrimal 
sac,  occurs  as  an  acute  and  as  a  chronic  affection. 
The  former  is  often  spoken  of  as  abscess  of  the  lacrimal 
sac;  the  latter  is  usually  denominated  blennorrhea  of 
the  sac. 

In  the  great  majority  of  cases  dacryocystitis  is  secon- 
dary to,  and  dependent  upon,  stricture  of  the  nasal 
duct.  Primary  injlammation  of  the  lacrimal  saCy 
that  is  to  say,  inflammation  occurring  independently 
of  stenosis  of  the  nasal  duct,  though  comparatively  a 
rare  affection,  is  occasionally  encountered.  It  is  met 
with  most  frequently  in  the  new-born,  usually  in  the 
form  of  a  mild  blennorrhea;  it  is  said  to  occur  also 
in  strumous  children,  and  it  may  be  brought  on  by 


132  PREVALENT    DISEASES    OF    THE    EYE. 

external  violence  or  through  the  entrance  into  the  sac 
of  an  irritant  fluid. 

Blennorrhea  of  the  Lacrimal  Sac. — Inflammation 
of  the  lacrmial  sac,  secondary  to  disease  ot  the  nasal 
duct,  usually  begins  as  a  chronic  affection.  It  is  un- 
attended by  pain,  and  manifests  itself  chiefly  through 
the  accumulation  of  tears  and  mucus  in  the  sac,  their 
regurgitation   through   the   puncta,    and   the   existence 


♦%^ 


Fig.  55. — Mucocele;     fracture    of    superior    maxilla;     exostoses    of    nasal 
bones  (de  Schweinitz). 

of  epiphora.  Frequently,  there  is  a  perceptible  disten- 
tion of  the  sac  [mucocele)  (Fig.  55),  which,  under  slight 
pressure  w^ith  the  tip  of  the  finger,  disappears,  the 
contents  of  the  sac  regurgitating  through  the  puncta 
and  flowing  over  the  front  of  the  eye,  or,  exceptionalh', 
if  the  stenosis  of  the  duct  is  incomplete,  escaping  into 
the  nose. 

This  state  of  chronic  catarrhal  inflammation  some- 


DISEASES    OF    THE    LACRIMAL    APPARATUS.         I33 

times  continues  indefinitely,  without  undergoing  appre- 
ciable change;  but,  on  the  other  hand,  through  the 
influence  of  "cold,"  a  slight  traumatism,  the  en- 
trance into  the  sac  of  a  pyogenic  organism  of  unusual 
virulence,  or,  as  seems  to  happen  not  infrequently, 
through  the  sudden  occlusion  of  the  canaliculi  at 
their  point  of  juncture  with  the  sac,  the  inflammation 
is  liable  at  any  moment  to  undergo  a  sudden  and 
acute  aggravation.  Severe  pain,  accompanied  by 
marked  edema  and  redness  of  the  lids,  and  often  of 
the  whole  side  of  the  face,  comes  on;  thick,  creamy 
pus  forms  in  the  sac,  and  decided  evidences  of  consti- 
tutional disturbance,  such  as  fever,  loss  of  appetite, 
sleeplessness,  etc.,  may  manifest  themselves.  Indeed, 
the  local  appearance  and  the  general  disturbance  of 
the  system  are  such  as  not  infrequently  to  lead  to  a 
mistaken  diagnosis  of  facial  erysipelas. 

These  are  the  symptoms  which  characterize  acute 
dacryocystitis,  or  abscess  of  the  lacrimal  sac 
(Fig.  56),  and  which,  in  many  cases  of  stricture  of 
the  nasal  duct,  recur  from  time  to  time  as  long  as  the 
occlusion  of  the  duct  is  permitted  to  remain. 

After  several  days  of  intense  suffering  the  integument 
over  the  sac  assumes  a  yellowish  appearance,  becomes 
thinned,  and,  if  left  to  itself,  usually  gives  way  at  a 
point  just  below  the  internal  palpebral  ligament,  per- 
mitting the  contents  of  the  sac  to  escape,  and  affording 
immediate  and  almost  complete  relief  from  suffering. 
Exceptionally,  the  inflammation  subsides  w^ithout  per- 
foration of  the  sac,  and  the  pus  escapes  ultimately 
through  the  canaliculi  and  puncta. 

After  the  contents  of  the  acutely  inflamed  lacrimal 
sac  have  been  evacuated,  either  spontaneously  or  by 
an    incision,   the   inflammation    rapidly   subsides,    and 


134 


PREVALENT    DISEASES    OF    THE     EYE. 


within  ten  days  or  two  weeks  the  opening  through 
which  the  discharge  has  occurred  usually  closes,  and 
the  sac  resumes  its  previous  condition  of  chronic  blen- 
norrhea. It  may  happen,  however,  that  the  cicatriza- 
tion of  this  opening  is  prevented  by  the  discharge 
through  it  of  tears  and  muco-pus,  and  thus  there  is 
established   the  troublesome  condition  known  as   lac- 


Fig.  56. — Acute  dacryocystitis  (author's  case). 


rimal  fistula — a  condition  which  may  persist  for  an 
indefinite  period  (Fig.  57). 

It  is  worthy  of  remark  that  during  an  acute  attack 
of  dacryocystitis  it  is  seldom  possible  to  empty  the 
distended  sac  by  pressure,  as  can  usually  be  done  in 
the  intervals  between  such  attacks.  From  this  it  would 
appear  likely  that  when  the  sac  is  unduly  distended  a 
valve-like  closure  of  the  canaliculi  at  their  point  of 
juncture  with  the  sac  takes  place;    and    it   seems  not 


DISEASES    OF    THE    LACRIMAL    APPARATUS.         I35 

improbable  that  such  an  occurrence  as  this,  which 
would  necessarily  interfere  with  the  previously  existing 
drainage  of  the  sac,  is  often  a  potent  factor  in  the 
causation   of  the  acute  outbreaks. 

Although  inflammation  of  the  lacrimal  sac,  through 
the  regurgitation  of  muco-pus  which  commonly  attends 
it,  not  infrequently  gives  rise  to  inflammation  of  the 
conjunctiva  and  cornea,  the  reverse — the  secondary 
involvement  of  the  lacrimal  sac  in  an  inflammation 
having  its  starting-point  in  the  superficial  ocular  tunics 


I'ig.  57. — Lacrimal  tistukc — a  tear-drop  escaping  from  the  fistula   on   the 
right  side  (Haab). 

— is  an  occurrence  of  extreme  rarity.  The  truth  of  this 
statement  is  strikingly  illustrated  in  gonorrheal  con- 
junctivitis; for,  though  the  gonococci  doubtless  find 
their  way  in  great  numbers  into  the  lacrimal  sac, 
dacryocystitis  as  a  complication  of  gonorrheal  ophthal- 
mia is,  so  far  as  I  can  learn,  practically  unknown. 

On  the  other  hand,  as  has  already  been  intimated, 
there  is  the  closest  pathological  sympathy  between  the 
drainage  apparatus  of  the  eye  and  the  nasal  passages, 
and  without  doubt,  in  the  majority  of  instances,  dacryo- 
cystitis is  traceable,  directly  or  indirectly,  to  nasal  disease. 


136  PREVALENT    DISEASES    OF    THE     EYE. 

Treatment. — From  what  has  been  said  regarding  the 
etiology  of  dacryocystitis — that  it  is  ahnost  invariably 
dependent  upon  stricture  of  the  nasal  duct — it  follows 
that  a  description  of  the  treatment  of  this  affection,  or, 
at  least,  of  the  chronic  variety  of  it,  is  practically  a 
description  of  the  treatment  of  stenosis  of  the  nasal 
duct,  of  which  we  shall  speak  presently.  It  will  be  in 
place,  however,  to  consider  here  the  treatment  of  acute 
dacryocystitis. 

It  does  not  often  happen  that  we  can  cut  short  an 
attack  of  acute  inflammation  of- the  lacrimal  sac;  but, 
if  the  case  is  seen  in  its  incipiency,  an  effort  should 
be  made  to  accomplish  this  result.  The  application  of 
a  lotion  of  boracic  acid  and  opium  (ext.  opii,  gr.  x-xv; 
acid,  boracic,  gr.  xl;  aquae  destil.,  .^iv),  and  the  ad- 
ministration of  an  energetic  cathartic  ("compound 
calomel  powder,"  gr.  x),  followed  by  liberal  doses  of 
sodium  pyrophosphate  (gr.  xx,  every  two  or  three  hours), 
are  the  measures  which  are  most  likely  to  prove 
effectual. 

If  these  measures  fail  to  subdue  the  inflammation, 
the  pad  of  absorbent  gauze,  wet  with  the  lotion  of 
opium  and  boracic  acid,  should  be  covered  with  a  piece 
of  oiled  silk  or  muslin,  or  rubber  protective,  to  give  it 
a  poultice-like  action  (a  convenient  and  cleanly  sub- 
stitute for  a  poultice),  and,  as  soon  as  it  is  evident  that 
pus  has  formed,  and  is  endeavoring  to  make  its  way 
to  the  surface,  a  free  incision  should  be  made  into  the 
distended  sac,  usually  at  a  point  beneath  the  internal 
palpebral  ligament.  As  such  an  incision  leaves  no 
perceptible  scar,  provided  it  is  made  in  the  direction 
in  which  the  skin  tends  to  wrinkle — that  is,  from  abo^■e 
and  toward  the  nose  downward  and  outward — it  is 
much  better  to  give  the  pus  free  exit  in  this  way  than 


DISEASES    OF    THE    LACRIMAL    APPARATUS.         I37 

to  attempt  to  drain  the  sac  by  simply  slitting  the  canalic- 
ulus. After  this  has  been  done,  and  until  the  discharge 
has  lessened  markedly,  the  application  of  the  gauze 
pads  should  be  continued  as  before.  Until  all  the  evi- 
dences of  acute  inflammation  of  the  sac  have  disappeared 
no  attempt — it  should  be  said  with  emphasis — ought  to 
be  made  to  deal  with  the  stenosis  of  the  nasal  duct  by 
the  introduction  of  probes  or  otherwise;  for  a  fresh 
outbreak  of  dacryocystitis  is  likely  to  be  the  result  of 
a   disregard   of  this   precaution. 

In  chronic  inflammation  of  the  lacrimal  sac,  if  for 
any  reason  treatment  of  the  strictured  nasal  duct  is 
not  practicable,  a  considerable  measure  of  relief  may 
be  obtained  from  slitting  the  lower  canaliculus,  and 
prescribing  a  collyrium  of  mercury  bichlorid  (i  :  12,000 
to  I  :  8000)  or  of  argyrol  (5  per  cent.)  or  protargol 
(2  per  cent.),  to  be  dropped  into  the  inner  corner  of 
the  eye  two  or  three  times  a  day,  explicit  instructions 
being  given  that,  before  each  instillation  of  the  "drops," 
the  sac  shall  be  emptied  of  its  contents  by  pressure 
with  the  finger-tip. 

It  is  well  to  bear  in  mind  that  abscesses  occasion- 
ally occur  in  the  neighborhood  of  the  lacrimal  sac 
{prelacrimal  abscess)  which,  from  their  appearance 
only,  cannot  well  be  distinguished  from  dacryocystitis. 
However,  the  history  of  the  case,  show^ing  the  absence 
of  pre-existent  lacrimal  disease,  will  usually  make  the 
diagnosis  plain. 

Stricture  of  the  Nasal  Duct.— In  order  to  com- 
prehend the  etiology  of  this  aff^ection,  one  needs  but  to 
call  to  mind  the  anatomical  and  histological  peculiar- 
ities of  the  membranous  lining  of  the  duct;  to  remember 
that  it  is,  at  once,  a  mucous  membrane  and  a  periostea! 
membrane;    that  it  contains  a  dense   plexus  of  veins. 


138  PREVALENT    DISEASES    OF    THE     EYE. 

resembling  those  of  the  turbinate  bodies;  and  that 
here  and  there  it  is  thrown  into  valve-Hke  folds,  which 
encroach  considerably  upon  the  lumen  of  the  canal. 
In  the  presence  of  such  conditions  it  is  evident  that 
even  a  trivial  inflammation  occurring  here  is  liable  to 
cause,  at  least,  a  transient  occlusion  of  the  duct;  and, 
further,  it  is  manifest  that,  though  the  inflammation 
may  begin  as  a  simple  catarrhal  process,  involving  only 
the  mucous  membrane,  it  is  apt,  if  it  be  prolonged  or 
become  more  intense,  to  extend  to  the  underlying  fibrous 
tissue,  and  so  develop  into  an  actual  periostitis.  Thus 
it  happens  that  the  transient  occlusion  of  the  duct 
caused  by  edema  of  the  mucous  membrane  and  en- 
gorgement of  the  underlying  venous  plexus,  which 
under  favorable  circumstances  passes  away  without 
leaving  any  permanent  ill  effects,  may  give  place  to 
a  persistent  stenosis,  dependent  upon  periosteal  and 
osteal  thickening. 

Again,  if  we  would  understand  how  it  is  that  the 
conditions  which  favor  such  permanent  occlusion  of 
the  nasal  duct  occur  as  often  as  they  do,  we  have  but 
to  recall  the  fact,  to  which  reference  has  already  been 
made,  that  this  canal,  although  an  appendage  of  the 
eye,  is  in  reality  a  part  rather  of  the  nasal  cavity  into 
which  it  opens,  and  that  its  relation  to  this  cavity, 
prone  as  it  is  to  inflammatory  affections,  is  as  close 
pathologically  as  it  is  anatomically. 

Watering  of  the  eyes,  as  is  well  known,  is  a  usual 
symptom  of  acute  rhinitis,  and  it  is  probable  that  in 
pronounced  cases  of  this  affection  the  mucous  membrane 
lining  the  lacrimal  drainage  apparatus  commonly  parti- 
cipates, to  a  greater  or  less  degree,  in  the  catarrhal  pro- 
cess. With  the  subsidence  of  the  rhinitis  the  lacrimal 
symptoms  usually  disappear,  and  the  parts  return  to  their 


DISEASES    OF    THE    LACRIMAL    APPARATUS.  I39 

normal  condition.  Exceptionally,  however,  because  of 
the  greater  intensity  of  the  inflammation,  the  occurrence 
of  a  second  or  third  attack  before  the  first  has  been 
recovered  from,  a  congenital  narrowness  of  the  duct, 
or  a  peculiar  susceptibility  of  the  lacrimal  passages  to 
disease  (a  susceptibility  which,  not  infrequently,  is 
inherited),  the  inflammation  of  the  lining  membrane 
of  the  duct  does  not  subside  with  the  nasal  aff'ection, 
but  assumes  the  more  serious  character  which  has  just 
been  described. 

In  this  way,  and,  perhaps,  still  more  frequently  from 
the  extension  of  chronic  inflammatory  affections  of  the 
nose  to  the  lacrimal  passages,  stricture  of  the  nasal 
duct,  which,  as  has  been  said,  is  the  usual  forerunner 
of  dacryocystitis,  commonly  arises. 

The  nasal  affections  of  inherited  and  of  acquired 
syphilis,  it  should  be  remarked,  are  especially  liable 
to  involve  the  lacrimal  apparatus.  Gummata  have 
been  met  with  in  the  lacrimal  sac,  as  well  as  in  the 
duct.  Tuberculosis  of  the  nose,  through  extension  to 
the  lacrimal  passages,  has  been  known  to  cause  occlu- 
sion of  the  nasal  duct.  The  exanthematous  fevers  also 
may  lead  to  this  condition,  as  a  consequence  of  the 
inflammation  of  the  nasal  mucous  membrane  which 
attends  them;  and,  it  may  be  added,  not  only  inflam- 
mation of  the  lacrimal  sac,  as  has  been  indicated,  but 
stricture  of  the  duct  is  occasionally  brought  about  by 
a  blow  upon  the  bridge  of  the  nose  or  in  the  region 
of  the   inner   canthus. 

As  to  the  location  of  the  strictures,  although  their 
most  common  situation  is  at  the  upper  extremity  of 
the  duct,  there  is  no  part  of  the  canal  in  which  they 
are  not  frequently  encountered.  Multiple  strictures,  at 
least  in  cases  of  long  standing,  are  the  rule.     As  they 


140  PREVALENT    DISEASES    OF    THE    EYE. 

are  the  outcome  of  periosteal  inflammation,  the  stric- 
tures are  ahnost  always,  in  part  at  least,  of  bony  struc- 
ture. In  form  they  may  be  circumscribed  and  annular 
(a  thin  bony  septum  being  occasionally  met  with)  or 
ill  defined  and  of  wide  extent,  involving  a  considerable 
part  of  the  length  of  the  canal.  A  stricture  located 
at  the  lower  extremity  of  the  duct,  it  is  well  to  bear  in 
mind,  is  more  easily  overlooked;  and  it  may  happen 
that  a  mistake  of  this  character  will  render  of  no  avail 
a  course  of  treatment  which  otherwise  would  prove 
successful. 

Treatment. — Of  the  many  ingenious  surgical  pro- 
cedures for  dealing  with  occlusion  of  the  nasal  duct 
which  have  been  suggested  from  time  to  time,  there  are 
but  very  few  which  have  for  us,  at  the  present  day, 
an  interest  that  is  other  than  historical. 

The  invaluable  suggestion  of  Bowman  (1857)  that 
the  canaliculus  should  be  slit  as  a  preliminary  step  to 
the  treatment  of  stenosis  of  the  nasal  duct  may  be  said 
to  mark  the  beginning  of  a  new  era  in  the  surgery  of  the 
lacrimal  apparatus.  The  great  merit  of  this  procedure 
is  that  it  renders  possible  the  use  of  lacrimal  probes 
sufficiently  large  to  completely  obliterate  the  strictures, 
and  restore  the  normal  caliber  of  the  canal.  It  was  not, 
however,  until  some  years  after  Bowman's  operation  was 
generally  adopted  that  the  opportunity  which  it  affords 
in  this  respect  was  fully  appreciated  and  taken  advan- 
tage of;  but,  when  this  finally  came  about,  the  treat- 
ment of  lacrimal  strictures  ceased  to  be  what  it  previ- 
ously had  been — an  opprobrium  of  ophthalmic  surgery. 

Dr.  E.  Williams,  of  Cincinnati,  and  Dr.  H.  D. 
Noyes,  of  New  York,  were  the  first  to  realize  the  in- 
adequate size  of  the  probes  employed  by  Bowman  and 
his  followers,  and  to  urge  the  necessity  of  using  probes 


DISEASES    OF    THE    LACRIMAL    APPARATUS.         I4I 

of  considerably  larger  caliber.  A  brief  experience  in 
the  treatment  of  diseases  of  the  lacrimal  apparatus  led 
me  to  a  similar  conclusion,  and  induced  me  (in  1877) 
to  undertake  the  measurement  of  a  large  number  of 
nasal  ducts  (in  the  dried  skull  and  in  the  cadaver) 
with  a  view  to  determining  the  usual  size  of  the  duct, 
and  how  large  a  lacrimal  probe  it  would  be  practi- 
cable, and  probably  advantageous,  to  employ.* 

As  a  result  of  these  measurements  (Fig.  58),  I  devised 
the  series  of  probes — sixteen  in  number,  the  smallest 

0         Bovkinan's  largest,  No.  6,  probe;  diameter  =   1.50  mm. 

^B      Author's  largest,  No.  16,  probe;  diameter  =  4  mm. 

•      Average    size    of    10    adult    nasal    ducts,    cadaver;    diameter  = 
4.47  +  mm. 

^^k     Largest  of  10  adult  nasal  ducts,  cadaver;  diameter  =  5.25  mm. 


Largest  of  70  bony  nasal  ducts;  diameter  =  7  mm. 

Fig.  58. — Diameters  of    probes,    and  of    nasal     ducts    as    determined  by 

author. 

size, No.  I,  having  a  diameter  of  0.25  of  a  millimetre, 
and  each  number  increasing  in  size  by  0.25  of  a  milli- 
metre, so  that  the  largest,  No.  16,  has  a  diameter  of  4 
mm. — which  I  have  used  since  with  great  satisfaction, 
and  which  are  now  quite  generally  employed.  The  ac- 
companying illustration  (Fig.  59)  represents  the  actual 
size  of  No.  15  and  No.  16,  the  largest  probes  of  the 
series,  and  shows  the  correct  shape  of  the  tips  and  the 
curve  which  experience  has  shown  to  be  most  convenient. 

*  "The  Use  of  Large  Probes  in  the  Treatment  of  Strictures  of 
the  Nasal  Duct,"  "Trans,  of  the  Medical  and  Chirurgical  Faculty 
of  Maryland,"  1877,  p.  154. 


142 


PREVALENT    DISEASES    OF    THE     EYE. 


Although  Other  ways  of  treating  strictures  of  the 
nasal  duct  are  advocated,  such  as  dividing  them  with 
a   suitably   shaped   knife,*   inserting  styles,   etc.,  their 


I. 


Fig.  59. — Author's  lacrimal  probe. 


Fig.  60.— Dr.  N.  R.  Smith's 
knife  for  dividing  strictures  of  the 
nasal  duct  (Norris  and  Oliver). 


*  This  plan  of  treatment  was  first  practised  (in  iS'46)  by  my 
grandfather,  the  late  Prof.  Nathan  R.  Smith,  of  Baltimore,  who 
devised  a  knife  of  peculiar  pattern  for  the  purpose  (Fig.  60).  Many 
years  afterw^ard  it  was  revived,  improved  upon,  and  brought  more 
prominently  into  notice  by  Stilling,  of  Cassel.  (See  the  author's  ar- 
ticle upon  " Diseases  of  the  Lacrymal  Apparatus"  in  Norris  and 
Oliver's  "System  of  Diseases  of  the  Eye,"  Vol.  III.) 


DISEASES    OF    THE    LACRIMAL    APPARATUS.         I43 

thorough  dilatation  by  means  of  probes  sufficiently 
large  for  the  purpose  is  the  method  which,  in  my  opin- 
ion, yields  by  far  the  best  results,  and  which  I  unhesi- 
tatingly commend  to  others. 

Unquestionably  there  are  cases  of  stenosis  of  the 
duct,  especially  such  as  are  associated  with  and  de- 
pendent upon  severe  chronic  nasal  disease,  that  are 
not  amenable  to  any  plan  of  treatment;  but  such  cases 
are  rare,  and,  apart  from  these,  the  dilatation  treatment 
with  large  probes,  if  systematically  carried  out,  com- 
monly yields  most  gratifying  results,  a  complete  and 
permanent  cure,  even  in  cases  of  long  standing,  being 
its  usual  outcome. 

Briefly  described,  the  method  of  dealing  with  stric- 
tures of  the  nasal  duct  which  long  experience  has  led 
me  to  place  such  confidence  in  is  as  follows: 

Cocain  (4  per  cent,  solution)  or  holocain  (i  per  cent, 
solution)  having  been  instilled  several  times  into  the 
inner  corner  of  the  eye,  and,  alternating  with  these  in- 
stillations, several  applications  of  adrenalin  solution 
(i  :  1000)  having  been  made,  a  No.  2  probe,  or  a  No.  i 
followed  by  a  No.  2,  is  passed  through  the  lower  canali- 
culus into  the  sac,  for  the  double  purpose  of  slightly 
dilating  the  punctum  and  canaliculus  and  of  discovering, 
and,  if  possible,  overcoming,  any  stricture  which  may 
exist  at  this  point.  If  a  stricture  too  firm  to  be  over- 
come by  either  of  these  probes  is  encountered  (the  usual 
site  of  such  strictures  being  at  the  juncture  of  the 
canaliculus  with  the  lacrimal  sac)  the  straight,  sharp- 
pointed  probe  (Fig.  51)  is  substituted,  and  with  a  drill- 
like motion  the  obstruction  is  penetrated.  This  pre- 
liminary probing  I  regard  as  important,  as  it  insures  the 
complete  division  of  the  canaliculus  which  is  to  follow. 

In  the  manner  already  described  (p.  128)  and  with 


144 


PREVALENT    DISEASES  OF    THE     EYE. 


the  Straight,  probe-pointed  knife  (Fig.  52)  the  canaH- 
culus  (always  the  lower  canaHculus)  is  now  divided 
well  up  to  its  juncture  with  the  sac.  The  next  step  is 
the  passage  of  the  probe  through  the  occluded  nasal 
duct,  as  large  a  probe  being  used  as  can  be  readily 
introduced  into  the  sac  through  the  divided  canaliculus. 
This  is  usually  a  No.  5,  exceptionally  a  No.  6,  probe. 
In  passing  the  probe  I  prefer,  as  in  dividing  the  canal- 
iculus, to  stand  behind  the  patient,  using  the  right  hand 
for  the  right  eye  and  the  left  hand 
for  the  left  eye,  because  the  patient's 
head  can  be  more  easily  steadied  in 
this  position,  and  because,  more- 
over, it  is  more  convenient  for  the 
operator. 

The  probe  selected,  which  pre- 
viously has  been  sterilized  bv  brief 
boiling,  and  anointed  with  sterile 
vaselin,  is  passed  in  the  usual  way, 
first,  horizontally,  along  the  divided 
canaliculus,  the  lid  being  kept  upon 
the  stretch  with  the  thumb  of  the 
opposite  hand,  until  its  point  has 
entered  the  sac  and  come  in  contact 
with  its  inner  wall;  then  it  is  turned  into  a  vertical  posi- 
tion, and  passed  slowly  through  the  duct  until  it  reaches 
the  floor  of  the  nose  (Fig.  61).  Provided  the  probe 
has  entered  fairlv  into  the  lacrimal  sac,  anv  reasonable 
amount  of  force  that  may  be  required  to  pass  it  through 
the  occluded  duct  is  considered  permissible,  care,  of 
course,  being  exercised  that  it  does  not  take  a  wrong 
direction.  The  probe  is  withdrawn  after  having  been 
allowed  to  remain  in  the  duct  for  from  ten  to  twenty 
minutes. 


Fig.  61. — Introduction 
of  lacrimal  probe. 


DISEASES    OF    THE    LACRIMAL    APPARATUS.  I45 

If,  as  sometimes  happens,  neither  a  No.  5  nor  a 
No.  4  probe  can  be  made  to  enter  the  sac  directly  after 
the  division  of  the  canahculus — an  indication  that  there 
is  an  undivided  constriction  at  the  juncture  of  the 
canahculus  and  the  sac,  or  that  the  point  of  the  probe 
has  caught  in  the  treshly  cut  tissues — an  attempt  is 
made  to  dilate  the  constriction  by  means  of  the  "sup- 
plementary probe"  (Fig.  62),  which  was  devised  to 
meet  this  particular  condition.* 

li  this  attempt  also  fails,  if  even  the  slender  tip  of 
this  probe  cannot  be  made  to  enter  the  sac,  an  interval 
of  forty-eight  hours  is  allowed  to  elapse  without  further 
effort;  when  the  difficulty  previously  encountered  will 


Fig.  62. — Author's    supplementary    lacrimal   probe   (about  two-thirds    ac- 
tual size). 

often  be  found  in  great  measure  to  have  disappeared. 
Should  this  not  prove  to  be  the  case,  an  opening  is  drilled 
through  the  constriction  with  the  straight,  sharp  probe 
(Fig.  51),  or  a  No.  5  probe  is  passed  along  the 
divided  canaliculus  to  the  point  of  resistance,  the  lid 
being  kept  well  upon  the  stretch,  and  is  then  turned 
vertically  and  forced  through  the  obstruction — a  pro- 
cedure, however,  which  it  is  desirable  to  avoid,  as  it 
may  result  in  making  a  false  passage  from  the  canalicu- 
lus directly  into  the  duct.  Exceptionally,  it  is  found 
necessary  to  divide  the  constriction  with  a  sharp-pointed 
knife,  for  which  purpose  a  narrow-bladed  Sichel  cataract 
knife  has  been  found  especially  convenient. 

*"Trans.  American  Ophthalmological  Society,"  1901,  p.  398. 


146  PREVALENT    DISEASES    OF    THE    EYE. 

During  the  early  stages  of  the  treatment  the  probing 
is  repeated  every  other  day,  usually  a  size  larger  probe 
being  passed  each  time.  Occasionally,  if  the  probe 
last  introduced  was  passed  very  easily,  a  size  is  skipped, 
while,  on  the  other  hand,  the  same  probe  is  passed 
more   than   once,  if    found   to    be   tighter   than    usual. 

The  size  of  the  largest  probe  which  it  is  desirable 
to  use  varies,  of  course,  in  different  cases,  but  it  is 
seldom  best  to  stop  short  of  No.  14;  for  it  is  to  be 
borne  in  mind  that  the  end  in  view  is  not  simply  the 
making  of  a  small  opening  through  the  strictures,  as 
was  formerly  done  with  such  unsatisfactory  results, 
but  their  complete  obliteration,  and  the  restoration 
of  the  normal  caliber  of  the  duct,  since  it  is  only  in 
this  way  that  frequent  relapses  are  to  be  avoided  and 
permanently  good  results  assured.  In  about  two- 
thirds  of  the  cases,  including  those  occurring  in  children 
as  well  as  those  in  adults,  the  No.  16  probe  is  used. 

In  passing  the  larger  probes  considerable  force  is 
sometimes  employed.  Experience  has  shown  not  only 
that  this  is  permissible,  but  that,  instead  of  being 
harmful  as  many  maintain  it  must  be,  the  effect  upon 
the  carious  walls  of  the  duct  is  distinctly  beneficial, 
the  result  being  not  unlike  that  produced  by  the 
curetting  of  diseased  bone  in  other  parts  of  the  body 
(Fig-  63). 

When  as  large  a  probe  has  been  introduced  as  is 
deemed  advisable,  the  interval  between  the  probings 
is  gradually  increased,  first  to  three  or  four  days,  then 
to  a  week,  a  fortnight,  and  finallv  to  a  month  or  two 
months;  and  when  several  of  these  longer  intervals 
have  elapsed,  without  any  tendency  to  recontraction 
having  manifested  itself,  the  case  is  dismissed  with 
full  assurance  that  a  permanent  cure  has  been  effected. 


DISEASES    OF    THE    LACRIMAL    APPARATUS. 


147 


Including  these  longer  intervals,  the  treatment  fre- 
quently extends  over  a  period  of  eight  or  ten  months; 
but  the  active  treatment,  involving  the  frequent  prob- 
ings,    is    comprised   within    as    many   weeks. 

The  improvement  occurs  much  more  rapidly  in  some 
cases  than  in  others,  so  that  the  length  of  time  during 
which  it  is  necessary  to  use  the  probes  varies  consider- 
ably. It  is  a  safe  rule  not  to  discontinue  the  treatment 
as  long  as  there  is  any  dacryocystitis  or  any  roughness 
of  the  walls  of  the  duct  noticeable  upon  passing  the 


Fig.  63. — Position  of  lacrimal  probes  introduced  through  lower  canaliculus. 

probe.  However,  as  it  sometimes  happens  that  the 
inflammation  is  kept  up  by  the  too  frequent  use  of 
the  probe,  it  is  well,  in  obstinate  cases,  to  try  the  effect 
of  lengthening  the  interval  between  the  probings. 

When  an  attempt  is  made  to  pass  a  probe  after  the 
lapse  of  six  or  eight  weeks,  it  is  sometimes  found  diffi- 
cult or  impossible,  owing  to  a  contraction  having  oc- 
curred at  the  juncture  of  the  canaliculus  and  the  sac, 
to  introduce  the  size  which  was  previously  employed. 
When  this  happens,  the  constriction  is  dilated  by  means 


148  PREVALENT    DISEASES    OF    THE     EYE. 

of  the  "supplementary  probe"  (Fig.  62),  after  which 
the  probe  previously  used  may  commonly  be  passed 
without  difficulty. 

No  attempt  is  made  to  inject  with  a  syringe  anti- 
septic or  other  solutions  into  the  lacrimal  sac.  Instead, 
a  collyrium  is  prescribed,  which  the  patient  is  instructed 
to  drop  into  the  inner  corner  of  the  eye  three  times  a 
day,  after  having  previously  pressed  out  the  contents 
of  the  sac  with  the  finger-tip.  The  collyrium  which 
has  been  found  most  useful  for  this  purpose  is  a  solution 
of  bichlorid  of  mercury  (i  :  12,000  to  i  :  8000)  with 
the  addition  of  sodium  chlorid  (i  per  cent.).  A  solu- 
tion of  alum  and  boracic  acid  (alum.,  gr.  j-ij;  acid, 
boracic,  gr.  x;  aquae  destil.,  5J)  has  also  given  good 
results,  and  so  has  a  weak  solution  (2  per  cent.)  of 
protargol. 

The  presence  of  a  lacrimal  fistula,  even  when  ac- 
companied by  caries  of  the  underlying  bone,  has  not 
seemed  to  call  for  special  treatment,  beyond  the 
snipping  off,  or  cauterization  with  silver  nitrate,  of 
exuberant  granulations,  if  they  happen  to  be  present; 
for  it  has  been  found  that,  as  soon  as  thorough  drainage 
has  been  established  by  the  passage  of  the  large  probes, 
the  fistula  heals,  and  the  carious  bone,  taking  on  a 
healthier  action,  becomes  re-covered  with  periosteum. 

The  frequent  dependence  of  disease  of  the  lacrimal 
apparatus  upon  nasal  catarrh  is  kept  in  mind,  and 
whenever  it  seems  to  be  indicated  treatment  is  directed 
to  the  nose.  A  solution  of  bichlorid  of  mercury,  sodium 
chlorid  and  glycerin  (hydrarg.  bichlorid.,  gr.  ss;  sodii 
chlorid.,  gr.  xv;  glycerin.,  5ss;  aquae  destil.,  givss) 
applied  to  the  nose  three  times  a  day,  by  means  of  a 
hand  atomizer,  has  been  found  especially  useful  under 
such  circumstances.     Constitutional  treatment  is  occa- 


DISEASES    OF    THE    LACRIMAL    APPARATUS.         I49 

sionally  called  for,  more  especially  when  the  lacri- 
mal affection  is  dependent  upon  inherited  or  acquired 
syphilis  or  upon  struma.  Ammonium  chlorid,  in  ten- 
grain  doses,  has  been  found  beneficial,  more  particu- 
larly when  nasal  catarrh  is  present. 

When  patients  from  a  distance  are  unable  to  remain 
under  treatment  as  long  as  is  thought  desirable,  it  has 
been  found  practicable,  after  the  duct  has  been  thor- 
oughly dilated,  to  teach  them  to  introduce  the  probes 
themselves.  In  this  way  relapses,  which  might  have 
occurred  from  a  too  early  discontinuance  of  the  treat- 
ment, have  been  avoided.  The  probe  represented  in 
Fig.  64  (usually  made  to  correspond  in  size  with  No. 


Fig.  64. — Author's  lacrimal  probe  for  use  by  patients  (actual  size). 

13)  was  devised  for  this  purpose,  and  has  proved  very 
useful. 

Electrolysis  has  been  tried  to  a  limited  extent,  in 
connection  with  the  large  probes,  to  hasten  the  obliter- 
ation of  the  strictures,   but  its  effect  was  inappreciable. 

In  intractable  cases  of  stenosis  of  the  nasal  duct, 
accompanied  by  persistent  dacryocystitis,  which  have 
failed  to  yield  to  less  radical  measures,  removal  of  the 
lacrimal  gland,  and  also  excision  of  the  lacrimal  sac 
or  its  destruction  by  means  of  caustics  or  by  means 
of  the  galvanocautery  or  thermocautery,  are  practised 
by  some  surgeons,  and,  it  is  claimed,  with  excellent 
results.  I  have  had  no  experience  with  these  pro- 
cedures, and  have  seldom  encountered  cases  in  which 
they  seemed  to  be  demanded.     As  to  the  use  of  styles, 


150  PREVALENT    DISEASES    OF    THE     EYE. 

which  some  authorities  still  commend,  I  abandoned 
them,  after  a  thorough  test  of  their  merits,  many  years 
ago,  because  the  good  which  they  accomplished  proved, 
in  almost  everv  instance,  to  be  but  temporarv. 

In  the  transient  occlusion  of  the  nasal  duct  which 
commonly  accompanies  the  dacryocystitis  of  the  new- 
born, previouslv  referred  to,  operative  treatment  is 
seldom  called  for,  since  the  blennorrhea  of  the  sac  and 
the  epiphora  usually  disappear  as  a  result  of  the  use 
of  one  of  the  collyria  which  have  been  spoken  of 
(bichlorid  of  mercury,  alum  and  boracic  acid,  or  pro- 
targol).  Should  this,  after  persistent  trial,  not  prove 
to  be  the  case,  however,  the  canaliculus  should  be 
divided,  and  the  duct  probed.  The  outcome  of  this 
treatment  is  usuallv  very  satisfactory,  and  it  is  seldom 
necessary  to  repeat  the  probing  oftener  than  five  or 
six  times.  In  a  case  of  this  character  which  was  oper- 
ated upon  when  the  child  was  fifteen  months  old,  a 
No.  12  probe  was  passed  without  difficulty,  and  a 
complete  cure  was  soon  effected. 


CHAPTER  V. 
DISEASES  OF  THE  CONJUNCTIVA, 

There  are  no  diseases  of  the  eye  with  which  it  is 
more  important  that  the  general  practitioner  should 
be  famihar  than  those  which  have  to  do  with  the  con- 
junctiva. This  is  true  not  only  because  they  are  of 
very  common  occurrence,  and  it  must  needs  happen 
that  he  will  often  be  called  upon  to  treat  them;  but 
because  it  is  frequently  impracticable  for  him  to  refer 
such  cases  to  the  specialist,  and  because,  moreover, 
there  is,  in  most  instances,  little  reason  why  he  should 
not  himself  be  able  to  deal  with  them  successfully. 

As  has  already  been  intimated,  the  usual  shortcoming 
of  the  general  practitioner  in  dealing  with  diseases  of 
the  conjunctiva  is  in  the  direction  of  faulty  diagnosis; 
for  the  indications  for  treatment  are  commonly  clear 
when  once  a  correct  diagnosis  has  been  reached.  It 
is  of  the  first  importance,  therefore,  that  he  should  be 
able  not  only  to  distinguish  conjunctival  inflammation 
from  inflammation  of  the  deeper  structures  of  the  eye, 
but  to  recognize  the  several  varieties  of  conjunctivitis, 
since  the  treatment  which  they  call  for  is  essentially 
diff'erent. 

The  medical  practitioner  unfamiliar  with  diseases 
of  the  eye  will  be  saved,  at  least,  a  goodly  number  of 
the  diagnostic  errors  into  which  he  is  apt  to  fall,  if 
he  will  bear  in  mind  that,  speaking  broadly,  inflamma- 
tion of  the  conjunctiva  is  not  accompanied  by  severe 
pain  or  pronounced  photophobia;    that  it  is  attended 

151 


152  PREVALENT    DISEASES    OF    THE     EYE. 

by  more  or  less  abundant  secretion  of  mucus  or  muco- 
pus;  that  it  does  not  appreciably  impair  sight,  except 
through  the  presence  of  this  discharge,  or  through 
implication  of  the  cornea,  as  in  purulent  or  tracho- 
matous conjunctivitis;  that  the  vascular  injection  which 
attends  it  is  made  up  largely  of  coarse,  superficial, 
movable  vessels,  which  run  irregularly  in  all  directions; 
that  the  injection  is  brick-red  in  color,  and  that  the 
redness  is  not  confined  to,  or  especially  marked  in  the 
neighborhood  of,  the  corneal  border;  and  if  he  will 
remember,  on  the  other  hand,  that  the  presence  of 
severe  pain,  accompanied  usually  by  photophobia  and 
lacrimation,  and  by  more  or  less  pronounced  obscura- 
tion of  vision,  and  attended  by  pericorneal  injection, 
pinkish  in  color,  and  composed  of  fine,  immovable, 
subconjunctival  vessels,  points  unmistakably  either  to 
corneal  inflammation  or  to  inflammation  of  the  deeper 
structures  of  the  eye,  such  as  iritis,  cyclitis,  glaucoma, 
etc. 

Again,  in  the  matter  of  ocular  therapeutics,  he  will 
have  made  a  long  stride  in  the  right  direction,  if  he 
will  further  bear  in  mind  that  in  the  treatment  of 
conjunctival  inflammations,  as  well  as  of  other  inflam- 
mations of  the  eye,  severe  remedies — applications  which 
cause  pain  and  which  increase  photophobia  and  lacri- 
mation— are,  almost  without  exception,  contraindicated. 

In  the  account  about  to  be  given  of  the  more  preva- 
lent aflPections  of  the  conjunctiva  the  difficulties  with 
which  the  general  practitioner  has  to  contend  in  the 
matter  of  differential  diagnosis  w411  be  kept  in  mind, 
and  every  effort  will  be  made  to  afford  him  assistance 
in  this  direction.  The  suggestions  regarding  treatment 
will  also  be  made  as  definite  and  concise  as  practicable. 

Hyperemia  of  the  Conjunctiva. — Hyperemia  of 


DISEASES    OF    THE    CONJUNCTIVA.  I53 

the  conjunctiva,  when  pronounced,  is  usually  accom- 
panied by  some  discomfort  of  the  eyes — a  sensation  of 
burning  or  itching — and  by  undue  lacrimation.  It 
occurs  as  a  transient  and  also  as  a  chronic  condition. 

Transient  or  acute  conjunctival  hyperemia  may 
arise  from  a  variety  of  causes,  and,  as  a  rule,  is  a 
matter  of  but  little  moment.  The  presence  of  a 
foreign  body  upon  the  cornea  or  conjunctiva,  exposure 
of  the  eyes  to  a  strong  wind,  to  undue  heat  or  light 
or  to  irritant  gases,  prolonged  use  of  the  eyes,  espe- 
cially with  imperfect  illumination,  crying,  etc.,  are 
some  of  the  causes  which  may  give  rise  to  it.  It  also 
marks  the  onset  of  most  superficial  inflammations  of 
the  eye,  and  is  a  frequent  accompaniment  of  acute 
rhinitis  and  of  facial  neuralgia. 

Chronic  hyperemia  of  the  conjunctiva,  a  condition 
of  greater  significance,  is  more  frequently  due  to  eye- 
strain, the  result  of  errors  of  refraction  or  anomalies 
of  the  ocular  muscles,  than  to  any  other  one  cause.  It 
may  be  dependent  also  upon  chronic  rhinitis,  inflam- 
mation of  the  lacrimal  passages,  trichiasis,  alcoholism, 
and  gout. 

In  the  treatment  of  this  condition  the  most  important 
consideration  is  the  removal  of  the  cause.  In  chronic 
hyperemia  the  refraction  and  the  muscular  balance  of 
the  eyes  should  be  examined,  and  glasses  should  be  pre- 
scribed if  found  to  be  indicated.  Nasal  or  lacrimal 
disease,  if  present,  should  be  treated,  and  measures 
should  be  taken  to  combat  any  disorder  of  the  system, 
such  as  a  gouty  diathesis,  which  might  be  a  factor  in 
the  causation  of  the  local  aff'ection.  As  supplementary 
measures,  a  collyrium  of  boracic  acid  (acid,  boracic,  gr. 
x;  aq.  destil.,  %])  or  of  boracic  acid  and  sulphate  of 
zinc    (zinci   sulphat.,  gr.  \;    acid,  boracic,  gr.  x;    aq. 


154  PREVALENT    DISEASES    OF    THE     EYE, 

destil.,  5i),  to  be  dropped  into  the  eyes  three  times  a 
day,  and,  especially  in  acute  cases,  the  application  to 
the  lids  of  cold  water  or  ice-cloths,  are  useful. 


CONJUNCTIVITIS. 

Whether  regarded  from  a  clinical  or  a  pathological 
point  of  view,  all  of  the  commonly  recognized  types  of 
conjunctivitis  may  very  properly,  and  with  practical 
advantage,  be  classified  as  follows:  First,  catarrhal  or 
simple  cofijunctivttis;  second,  purulent  or  gonorrheal 
conjunctivitis;  third,  croupous  or  membranous  con- 
junctivitis; fourth,  diphtheritic  conjunctivitis;  filth, 
follicular  conjunctivitis;  sixth,  trachomatous  or  granu- 
lar conjunctivitis;  seventh,  vernal  conjunctivitis  or 
spring  catarrh;  and,  eighth,  phlyctenular  or  scrofulous 
conjunctivitis. 

As  a  rule,  it  is  not  difficult  to  differentiate  these 
several  varieties,  which,  though  they  possess  certain 
features  in  common,  exhibit  other  well-marked  and 
distinctive  characteristics;  but,  occasionally,  the  most 
experienced  observer  may  find  himself  at  fault  in  this 
respect,  being  unable  to  determine,  simply  from  in- 
spection of  the  eye,  to  w^hich  class  a  particular  case 
should  be  assigned.  However,  the  history  of  the  case, 
and  especially  its  behavior  under  treatment,  will  usu- 
ally dispel  any  doubt  upon  this  point.  With  the  ex- 
ception of  phlyctenular  conjunctivitis  and  of  diph- 
theritic conjunctivitis,  all  of  these  different  types  of 
conjunctival  inflammation  are  essentially  local  dis- 
orders. As  regards  their  etiology,  much  has  yet  to 
be  learned,  though  considerable  progress  has  been 
made  in  this  direction  within  the  past  few  years. 

Catarrhal  or  Simple  Conjunctivitis. — This  variety 


DISEASES    OF    THE    CONJUNCTIVA.  155 

of  inflammation  of  the  conjunctiva,  which  is  of  very 
common  occurrence,  is  met  w^ith  as  an  acute,  and,  less 
frequently,  as  a  chronic,  affection. 

In  a  well-marked  attack  of  acute  catarrhal  conjunc- 
tivitis the  patient  complains  of  a  sensation  as  though 
sand  were  in  the  eyes,  exhibits  some  little  dread  of 
light,  and,  upon  being  questioned,  commonly  states 
that  his  eyes  smart  when  he  attempts  to  read  or  write, 
that  after  sleep  the  lashes  are  stuck  together  by  dis- 
charge, and  that  during  the  day  some  discharge  col- 
lects about  the  inner  cornea  of  the  eyes  and  upon  the 
lid-margins,  and  requires  to  be  wiped  away  from  time 
to  time.  Upon  inspection,  the  lids  will  be  found  to 
be  somewhat  edematous,  and  the  bulbar  conjunctiva 
to  be  markedly  injected  and  of  a  nearly  uniform  brick- 
red  color,  the  injected  blood-vessels  being  superficial, 
coarse,  tortuous,  and  movable.  The  palpebral  con- 
junctiva also  will  be  congested  and  somewhat  swollen, 
and  strings  of  mucus  will  be  discovered  upon  the  inner 
surface  of  the  lids  and  in  the  retrotarsal  folds.  The 
cornea  and  iris  present  a  normal  appearance,  and  the 
pupil  responds  to  light  as  in  health  (Plate  III,  Fig.  i). 

In  the  milder  cases,  which  are  the  more  common, 
the  lids  are  not  edematous,  and  the  bulbar  conjunctiva 
is  but  slightly,  if  at  all,  injected,  the  evidences  of  in- 
flammation being  limited  to  the  palpebral  conjunctiva 
and  to  the  retrotarsal  folds,  the  diagnosis,  under  such 
circumstances,  being  based  mainly  upon  the  appearance 
of  the  inner  surface  of  the  lids,  the  sudden  onset  of 
the  attack,  and  the  gumming  of  the  eyelashes  during 
sleep.  Another  feature  of  acute  catarrhal  conjunc- 
tivitis, which  is  of  decided  diagnostic  value,  is  that  it 
is  essentially  a  binocular  affection.     One  eye,  it  is  true. 


156  PREVALENT    DISEASES    OF    THE     EYE. 

is  often  attacked  before  the  other,  but  within  twenty- 
four  hours  both  eyes  are  sure  to  be  affected. 

A  variety  of  phlyctenular  conjunctivitis — the  ca- 
tarrhal type — very  closely  resembles  acute  catarrhal 
conjunctivitis;  but  as  this  affection  is  usually  monocu- 
lar, and  is  commonly  accompanied  by  blepharitis, 
eczema  of  the  lids  or  face,  or  other  signs  of  constitu- 
tional disorder,  it  is  not  difficult,  as  a  rule,  to  recognize 
its  true  character.  The  character  of  the  conjunctival 
injection,  the  absence  of  changes  in  the  cornea  or  iris, 
the  normal  size  and  reaction  of  the  pupil,  and  the  non- 
existence of  pain  suffice  to  differentiate  the  disease 
under  consideration  from  inflammation  of  the  cornea 
or  iris  and  from  inflammatory  glaucoma.  As  the 
symptoms  produced  by  the  presence  of  a  foreign  body 
upon  the  cornea  or  beneath  the  upper  lid  very  closely 
resemble  those  of  a  commencing  conjunctivitis,  one 
should  be  careful  to  avoid  falling  into  a  diagnostic 
error  of  this  character. 

Acute  catarrhal  conjunctivitis,  which  occasionally 
assumes  an  epidemic  character,  and  under  such  cir- 
cumstances is  popularly  known  as  "pink  eye,"  is 
unquestionably,  though  not  markedly,  contagious.  As 
to  its  etiology,  there  can  be  no  doubt  that  in  most 
instances  it  is  of  bacterial  origin.  "Cold"  probably  is 
at  times  a  factor  in  its  causation;  but  doubtless  acts 
chiefly  by  rendering  the  conditions  more  favorable 
for  the  development  of  the  invading  bacteria.  The 
Weeks  bacillus  and  the  pneumococcus  are  the  micro- 
organisms which  are  most  frequentlv  concerned  in  its 
production. 

Under  favorable  hygienic  conditions  the  disease  is 
usually  self-limited,  and  disappears  within  ten  days 
or   a   fortnight;    but  occasionally,  when   neglected,  it 


DISEASES    OF    THE    CONJUNCTIVA.  1 57 

runs  a  protracted  course,  lasting,  perhaps,  for  many 
weeks. 

Treatment. — The  treatment  of  this  variety  of  con- 
junctivitis, which  has  proved  so  efficacious  that  I 
seldom  have  occasion  to  employ  other  measures,  con- 
sists in  the  use  of  a  collyrium  of  zinc  sulphate  and 
boracic  acid  (zinci  sulphat.,  gr.  ss;  acid,  boracic,  gr. 
x;  aq.  destil.,  oj),  which  is  dropped  into  the  eyes  three 
times  a  day,  and  the  application  ot  a  bland  ointment 
to  the  lids  at  bed-time.  For  this  latter  purpose  *'cold- 
cream,"  to  which  boracic  acid  may  be  added  in  the 
proportion  of  five  grains  to  the  dram,  is  well  adapted. 
When  the  eyes  are  more  than  usually  irritable  and 
uncomfortable,  relief  is  afforded  by  the  application  to 
the  lids  of  pads  of  absorbent  gauze  wet  with  a  lotion 
of  opium  and  boracic  acid  (ext.  opii.,  gr.  x;  acid, 
boracic,  gr.  xl;  aq.  destil.,  oiv).  In  the  event  of  this 
treatment  not  proving  promptly  efficacious,  a  weak 
solution  of  argyrol  (5  per  cent.)  or  protargol  (2  per  cent.) 
may  be  substituted  for  the  zinc  and  boracic  acid,  being 
dropped  into  the  eyes  three  times  a  day. 

Chronic  catarrhal  conjunctivitis,  which,  as  has  been 
said,  is  less  common  than  the  acute  type,  owes  its 
chronicity,  as  a  rule,  to  some  extraneous  cause.  Among 
the  conditions  that  may  give  rise  to  it  may  be  men- 
tioned accommodative  strain,  disease  of  the  lacrimal 
apparatus — especially  when  attended  by  blennorrhea 
of  the  lacrimal  sac — partial  ectropion,  chronic  rhinitis, 
unfavorable  hygienic  surroundings,  as  in  crowded  re- 
formatories, etc.,  and  habitual  exposure  of  the  eyes  to 
irritating  gases  or  to  heat  and  dust.  The  conjunctival 
injection  and  discharge  may  be,  but  usually  are  not, 
pronounced. 

Treatment. — The    collyrium    of   zinc    sulphate    and 


158  PREVALENT    DISEASES    OF    THE    EYE. 

boracic  acid,  as  recommended  in  the  acute  form  of  the 
disease,  is  the  most  efficacious  local  remedy;  but  of 
greater  importance  is  it  to  discover,  and,  if  possible, 
to  eliminate,  the  condition  upon  which  the  affection 
depends.  Any  refractive  or  muscular  anomaly  found 
to  be  present  should  be  corrected  by  the  careful  adjust- 
ment of  glasses;  disease  of  the  lacrimal  apparatus  or 
of  the  nose,  if  it  exists,  should  receive  attention;  the 
canaliculus  should  be  slit,  if  there  is  eversion  of  the 
punctum;  and  the  patient's  surroundings  and  his 
occupation,  if  they  are  such  as  to  favor  the  continu- 
ance of  the  disease,  should,  if  possible,  be  changed  for 
the  better.  Good  food  and  tonics — iron,  quinin,  and 
strychnin,  especially — by  building  up  the  system  will 
often  accomplish  much. 

Purulent  or  Gonorrheal  Conjunctivitis. — This 
severe  type  of  conjunctival  inflammation  is  met  with 
in  the  new^-born — the  so-called  ophthalmia  neonatorum 
— as  a  result  of  infection  of  the  eyes  during  the  passage 
of  the  child's  head  through  the  vagina,  and  in  later 
life  in  consequence  of  accidental  inoculation  of  the 
eyes  with  gonorrheal  discharge  from  a  specific  urethri- 
tis or  vaginitis,  or  from  a  previously  infected  eye. 
The  purulent  conjunctivitis  of  the  infant  and  the 
gonorrheal  ophthalmia  of  the  adult  are,  therefore, 
essentially  one  and  the  same  disease,  each  being  due 
to  inoculation  of  the  conjunctiva  with  the  gonococcus. 
(See  Plate  II,  Fig.  i.) 

In  purulent  conjunctivitis  the  inflammation  is  much 
more  intense  than  in  catarrhal  conjunctivitis.  The 
discharge,  which  is  thick  and  creamy  and  distinctly 
purulent,  is  very  profuse,  so  that  it  overflows  the  lids, 
and  runs  down  upon  the  cheek.  The  lids  are  greatly 
swollen,  often  of  a  dusky  red  color,  and  so  tense  that 


PLATE  II. 


Fxo.E 


"tX. 


kits 


Fja.m 


dj'fi^ 


^-%^'^ 


i^ 


Fia.W 

%■■ 

■.i*^ 

r# 

r' 

*# 


Fig.  I. — Discharge  from  Right  Eye  in  a  Case  of  Purulent  Con- 
junctivitis;   GoNOCOCCi  Numerous  in  Cells  (Stephenson). 

Fig.  II. — Bacillus  of  Weeks  in  Pure  Culture  (from  a  Photo- 
graph)  (Weeks). 

Fig.  III. — Conjunctival  Secretion  from  Acute  Contagious  Con- 
junctivitis; Polynuclear  Leukocy'tes  with  the  Bacillus  of  Weeks; 
P,  Phagocy'te  Containing  Bacillus  of  W^eeks;  Immers.  yV,  Oc.  iii 
(Morax). 

Fig.  IV. — Secretion  from  a  Case  of  Conjunctivitis,  Showing 
Pneumococci;   Immers.  yV,  Oc  iii  (Morax). 


DISEASES    OF    THE    CONJUNCTIVA.  I59 

it  is  usually  impossible  to  evert  them  (Plate  III,  Fig. 
2).  The  bulbar  conjunctiva  is  intensely  injected,  and 
so  chemotic  that  it  overlaps  the  cornea,  and  may  even 
hide   it   completely   from   view. 

As  a  rule,  in  ophthalmia  neonatorum  the  disease  runs 
a  less  malignant  course,  and  the  prognosis  is  less  grave, 
than  in  the  adult.  This,  it  would  seem,  is  largely  because 
of  the  fact  that  the  discharge  which  infects  the  eyes  of 
infants  is  seldom  due  to  a  recently  acquired  gonorrhea, 
whereas  in  adults  the  inoculation  is  more  apt  to  occur 
during  the  height  of  the  urethritis  or  vaginitis,  when 
the  infectious  power  of  the  discharge  is  greatest.  Apart 
from  this,  however,  it  would  appear  that  the  eyes  of 
the  new-born  are  capable  of  withstanding  gonorrheal 
infection  better  than  are  those  of  adults.  The  interval 
between  the  inoculation  of  the  eye  and  the  appearance 
of  the  first  signs  of  the  disease — which  at  the  outset 
are  much  like  those  of  a  well-marked  attack  of  acute 
catarrhal  conjunctivitis — is  somewhat  greater  in  the 
infantile  than  it  is  in  the  adult  form  of  the  affection, 
the  incubation  period  in  the  latter  being  from  twelve 
to  forty-eight  hours,  whereas  in  the  former  it  is  usually 
from  forty-eight  to  seventy-two  hours.  In  ophthal- 
mia neonatorum  (Fig.  65)  both  eyes  are  usually  affected, 
because  each  is  almost  sure  to  be  inoculated  with  the 
vaginal  discharge;  in  adults,  on  the  other  hand,  the 
disease  is  commonly  monocular,  though  there  is  always 
great  danger  that  the  second  eye  may  become  affected 
through  the  transference  of  discharge  from  the  one  first 
involved. 

The  disease  runs  a  tedious  course,  and,  even  when 
promptly  and  carefully  treated,  is  seldom  cured  under 
four  to  six  weeks.  Severe  pain,  marked  photophobia, 
and  lacrimation  characterize  the  height  of  the  attack. 


i6o 


PREVALENT    DISEASES    OF    THE     EYE. 


The  great  danger  to  be  feared,  in  both  forms  of  the 
disease,  is  necrosis  of  the  cornea  (Fig.  66).  This 
probably  results,  not  infrequently,  from  a  secondary 
infection;  but  it  is  due,  primarily,  to  the  nutri- 
tion   of    the    cornea    being    seriously    interfered    with 


Fig.   65. —  Purulent  (gonorrheal)  conjunctivitis  in  the  new-ljurn  ( tlaab). 


^ 


Fig.  66. —  Extensive  necrosis  of  the  cornea  (Ramsay). 


through  the  intensity  of  the  conjunctival  inflammation. 
Complete  destruction  of  the  cornea,  which  is  by  no 
means  uncommon,  necessarily  involves  loss  of  useful 
vision;  but,  if  the  destruction  is  not  complete,  a 
considerable  amount  of  sight  may  be  regained,  either 


/A 

4 


PLATE  111. 


Fir,.   I. — Acute  Catarrhal  Conjunctivitis. 


-:^^A,\s:fv^ 


tv'r 


Fig.  2. — Purulent  Conjunctivitis  (Gonorrheal). 


f 


"^^fff^ 


.<? /U.cot^c.U  |.- 


)  'yoi- 


Fig.  3. — Acute   Trachomatous  Conjunctivitis  (Papillary  Variety). 


DISEASES    OF    THE    CONJUNCTIVA.  l6l 

with  or  without  the  help  of  an  iridectomy.  When  the 
discharge,  instead  of  being  thick  and  creamy,  is  thin 
and  watery,  and  is  accompanied  by  a  membranous 
exudation  upon  the  surface  of  the  palpebral  or  bulbar 
conjunctiva  and  by  a  plastic  infiltration  into  the  sub- 
conjunctival cellular  tissue,  the  prognosis  is  distinctly 
unfavorable,  and  the  danger  of  corneal  complications 
very  much  greater. 

Although  more  tractable  than  the  adult  form  of 
the  disease,  ophthalmia  neonatorum,  because  its 
treatment  is  so  often  neglected,  is  the  most  fruitful 
source  of  incurable  blindness.  According  to  the  sta- 
tistics gathered  by  Magnus,  twenty-four  per  cent,  of 
the  inmates  of  the  institutions  for  the  blind  in  the  differ- 
ent countries  of  Europe  owe  their  loss  of  sight  to  this 
one  disease — a  showing  wholly  inexcusable,  as  it  is 
largely  the  result  of  unpardonable  neglect  and  ignorance 
on  the  part  of  those  having  the  care  of  the  new-born. 

One  of  the  not  very  unusual  consequences  of  gonor- 
rheal conjunctivitis  is  anterior  staphyloma.  (See  Plate 
VI,  Fig.  I.)  In  the  less  severe  cases,  or  in  those  in 
which  treatment  has  been  begun  promptly,  necrosis  of 
the  cornea,  if  it  occurs,  is  more  apt  to  be  circumscribed. 
Under  such  circumstances  an  opacity  of  the  cornea  is 
left,  and  to  this  a  knuckle  of  the  iris  is  frequently  adher- 
ent (anterior  synechia).  (See  Fig.  lOO.)  The  degree 
of  impairment  of  vision  in  such  cases  will  depend  upon 
the  density  and  the  location  of  the  opacity,  whether  it 
is  central  or  peripheral,  and  upon  the  situation  of  the 
displaced  pupil. 

Treatment. — As  a  preliminary  step  to  the  employment 
of  remedial  measures,  if  there  be  any  doubt  as  to  the 
diagnosis,  the  discharge  from  the  eye  should  be  sub- 
jected to  microscopic  examination,   in  order  that  the 


l62  PREVALENT    DISEASES    OF    THE    EYE. 

presence  or  absence  of  the  gonococcus  may  be  deter- 
mined. Its  presence  in  the  discharge  definitely  estab- 
Hshes  the  diagnosis  (Fig.  67).  Failure  to  find  it  at  one 
examination,  however,  is  not  conclusive.  Therefore,  if 
the  general  symptoms  point  to  gonorrheal  infection  re- 
peated microscopic  examinations  should  be  made,  and, 
meantime,  it  is  safest  to  treat  the  case  as  though 
its  specific  character  had  been  established.  The  fact 
that  the  disease  is   acquired   at  times  in   an   entirely 


b 

Fig.  67. — a,  Gonococci  free  and  in  the  cells;   h,  gonococci  in  the  conjunctival 
tissues  (Bumm). 

innocent  manner,  and  by  persons  who  have  not  them- 
selves had  gonorrhea  of  the  genito-urinary  tract,  should 
not  be  lost  sight  of. 

To  secure  the  best  results,  it  is  essential  that  the 
treatment  should  be  begun  promptly,  and  that  it  should 
be  carried  out  intelligently  and  assiduously;  for  there 
is  no  other  disease  of  the  eyes,  it  may  be  remarked, 
which  demands  such  unremitting  attention. 

Until  the  disease  is  well  under  control,  that  is  to  say, 


DISEASES    OF    THE    CONJUNCTIVA.  163 

until  there  has  been  a  decided  abatement  of  the  con- 
junctival inflammation,  of  the  edema  of  the  lids,  and 
of  the  discharge,  the  eye  should  be  bathed  as  often  as 
every  hour  or,  if  practicable,  every  half  hour,  day  and 
night,  with  a  saturated  solution  (gr.  xviij  to  ,^j)  of 
boracic  acid,  pledgets  of  absorbent  cotton,  wet  with 
this  solution,  being  used  to  douche  the  eye,  and  to  re- 
move the  discharge  from  the  lids  and  from  the  con- 
junctival sac.  While  this  should  be  done  as  thor- 
oughly as  practicable,  it  should  be  done  with  a  gentle 
hand,  and  the  greatest  care  should  be  exercised  not 
to  abrade  the  corneal  epithelium,  since  this  accident 
materially  increases  the  danger  of  corneal  ulceration. 

In  addition  to  this  careful  cleansing  ot  the  eye,  in 
the  adult  form  of  the  disease  ice-cloths,  if  found  to 
afford  relief,  as  is  usually  the  case,  should  be  applied 
constantly  to  the  lids.  The  only  contraindication  to 
their  use  is  the  existence  of  a  thin,  watery  discharge, 
accompanied  by  a  membranous  exudation  upon  the 
surface  of  the  conjunctiva.  In  such  cases  the  likeli- 
hood of  corneal  necrosis — always  great,  as  has  been 
pointed  out — may  be  increased  by  the  depressing 
effect  of  cold;  therefore,  until  the  character  of  the 
discharge  changes,  until  it  becomes  purulent,  it  may 
be  desirable  even  to  employ  hot  fomentations  instead 
of  the  cold  compresses. 

The  "ice-cloths,"  consisting  of  pads  of  absorbent 
gauze  made  cold  by  lying  upon  a  block  of  ice,  which 
is  kept  close  at  hand,  must  be  changed  frequently 
to  afford  the  best  results.  An  intelligent  and  not  too 
awkw^ard  patient  may  be  trusted  to  carry  out  this  feature 
of  the  treatment  himself.  In  ophthalmia  neonatorum 
the  application  of  cold  is  not,  in  my  judgment,  called 
for.     In  the  first  place,  it  is  impracticable  to  apply  it 


164  PREVALENT    DISEASES    OF    THE     EVE. 

effectively,  and,  in  the  next  place,  as  abundant  experi- 
ence proves,  the  withholding  of  it  does  not  influence 
unfavorably  the  progress  of  the  disease. 

The  other  measure  of  importance  in  the  treatment 
of  purulent  ophthalmia  consists  in  the  careful  appli- 
cation of  a  sufficiently  strong  solution  of  argyrol  or 
protargol.  Formerly,  in  common  with  most  ophthal- 
mic surgeons,  I  employed  in  this  disease  silver  nitrate, 
usually  in  two  per  cent,  solution;  but  my  experience 
with  these  newer  agents  has  been  so  eminently  satis- 
factory that  I  now  feel  warranted  in  using  one  or  the 
other,  as  a  matter  of  routine,  instead  of  the  silver  nitrate. 
The  advantages  of  argyrol  and  protargol  are  that  they 
are  more  penetrating  in  their  action,  that  they  seem  to 
control  the  inflammation  more  effectually,  and  that 
even  the  strongest  solutions  are  far  less  irritating  than 
are  the  comparatively  weak  solutions  of  the  older  salt. 
To  be  effective,  however,  it  is  essential  that  they  should 
be  used  in  strong  solution.  A  forty  per  cent,  solution 
(forty  parts  to  sixty  parts  of  water)  is  about  a  saturated 
solution  of  protargol,  and  this  is  the  strength  in  which 
I  am  in  the  habit  of  using  it,  one  application  being 
made  to  the  eye  daily,  in  addition  to  which  a  weaker 
solution  (ten  to  twenty  per  cent.)  is  applied  twice  each 
day.  Argyrol,  being  more  soluble,  can  be  used  in 
stronger  (fifty  per  cent.)  solution,  and,  being  less  irri- 
tating, can  be  applied  more  freely — as  often  as  three 
times  a  day. 

When  practicable,  the  application  should  be  made 
to  the  everted  lids,  by  means  of  a  cotton  mop;  but  when, 
as  usually  happens,  it  is  impracticable  to  evert  the  lids 
the  solution  should  be  applied,  as  thoroughly  as  possible, 
to  the  palpebral  and  bulbar  conjunctiva  with  a  mop  or 
an  eye-dropper,  as  may  be  found  more  effective.     An- 


DISEASES    OF    THE    CONJUNCTIVA.  165 

Other  useful  measure  is  the  instillation,  once  or  twice 
a  day,  ot  a  sterile  solution  ot  atropin — a  four-grain-to- 
the-ounce  solution  in  the  case  of  adults,  a  one-grain 
solution  in  infants.  This,  besides  affording  the  patient 
a  measure  of  relief,  favorably  influences  any  corneal 
complication  which  may  be  present. 

In  ophthalmia  neonatorum  both  eyes,  as  has  been 
stated,  are  usually  infected  at  birth,  and  when  this  is 
not  the  case  subsequent  infection  of  the  second  eye 
is  almost  sure  to  occur,  in  spite  of  any  efforts  which 
may  be  made  to  prevent  it.  In  the  adult  form  of  the 
disease,  on  the  other  hand,  while  the  danger  of  involve- 
ment of  the  fellow-eye  is  always  great,  it  is,  as  a  rule, 
possible  with  proper  precautions  to  avoid  this.  There 
are  several  ways  in  which  infection  of  the  sound  eye 
may  occur.  The  greatest  danger  is  that  the  patient 
may  transfer  the  discharge  from  one  eye  to  the  other 
W'ith  his  fingers.  There  is  also  the  possibility  that  in 
bathing  the  affected  eye  some  of  the  pus  may  find  its 
way  into  the  other  eye;  and,  again,  if,  through  lack 
of  attention,  the  discharge  is  allowed  to  accumulate, 
it  may  flow  across  the  bridge  of  the  nose,  and  thus 
reach  the  sound  eye. 

To  lessen  the  risk  of  the  second  eye  becoming  in- 
fected, it  is  the  practice  with  many  surgeons  to  seal  up 
this  eye  hermetically  by  means  of  what  is  known  as 
Buller's  shield  (Fig.  68).  This  consists  of  a  watch-glass 
secured  between  two  suitably  shaped  pieces  of  rubber 
adhesive  plaster,  in  each  of  which  a  circular  opening, 
smaller  than  the  watch-glass,  has  been  cut.  This  is 
fastened  over  the  eye  in  such  manner  as  to  permit  free 
movements  of  the  lids,  being  applied  with  exactness  to 
the  brow%  side  of  the  nose,  and  lower  margin  of  the  orbit. 
To  render  it  more  secure,  reinforcing  strips  of  plaster 


l66  PREVALENT    DISEASES    OF    THE     EYE. 

should  be  used,  and,  as  infection  is  most  apt  to  occur 
at  the  nasal  edge  of  the  shield,  a  coating  of  collodion 
should  be  applied  here.  The  employment  of  the  watch- 
glass  (the  suggestion  of  Dr.  Buller)  enables  the  patient 
to  use  the  eye,  and  the  surgeon  to  inspect  it,  and  to 
watch  for  signs  of  commencing  inflammation. 

An  objection  to  the  use  of  the  shield  is  that  one 
seldom  knows,  when  a  case  of  monocular  purulent 
conjunctivitis  comes  under  observation,  whether  in- 
fection of  the  other  eye  may  not  have  occurred  already. 


Fig.  68. —  Buller's  shield  (Hansell  and  .Sweet). 

If  this  has  happened,  it  is  of  the  utmost  importance, 
in  order  that  no  time  should  be  lost  in  the  employment 
of  energetic  therapeutic  measures,*  that  w^e  should  be 

*The  advice  given  in  most  te.xt-books  upon  diseases  of  the  eye, 
that  in  gonorrheal  conjunctivitis  the  use  of  silver  nitrate  should  not 
be  begun  too  early,  should  not  be  commenced,  in  fact,  until  the  dis- 
charge has  assumed  a  distinctly  purulent  character,  is,  in  my  opinion, 
wholly  bad.  The  sooner  the  silver  salt  (whether  the  nitrate  or  pro- 
targol  or  arg^'rol)  is  begun,  the  greater  is  the  probability  that  the 
disease  will  be  kept  under  control,  and  that  the  eye  will  be  saved. 
That  I  have  never  lost  the  second  eye,  when  it  became  involved 
while  the  case  was  under  my  observation,  I  attribute  to  the  fact  that 
the  nature  of  the  affection  was  recognized  at  the  very  outset,  and  that 
energetic  treatment  (the  use  of  a  silver  salt)  was  begun  without  a 
moment's  delay. 


DISEASES    OF    THE    CONJUNCTIVA.  167 

able  to  detect  the  very  first  signs  of  beginning  conjunc- 
tivitis, and,  unquestionably,  this  cannot  be  done  as  well 
when  the  shield  is  in  position.  Moreover,  the  confin- 
ing effect  ot  the  shield  (although,  with  the  view  of  ob- 
viating this,  its  temporal  edge  is  usually  left  free  for 
ventilation)  tends  of  itself  to  excite  a  conjunctivitis 
of  catarrhal  type,  which  must  necessarily  befog  the 
situation. 

In  addition  to  warning  the  patient  as  to  the  risk  of 
infecting  his  sound  eye,  it  is  the  duty  of  the  physician 
to  impress  upon  those,  nurses  or  others,  who  may  have 
charge  of  a  case  of  gonorrheal  conjunctivitis,  how 
important  it  is  that  they  should  exercise  the  greatest 
care  to  guard  against  infection  not  only  of  the  patient's 
other  eye  but  of  their  own  eyes  and  of  the  eyes  of  others 
about  them.  He  should  instruct  them  not  to  touch 
the  patient's  sound  eye  with  infected  fingers;  to  be 
careful,  in  bathing  and  making  applications  to  the 
affected  eye,  not  to  permit  any  discharge  or  any  possi- 
bly infected  fluid  to  find  its  way  into  the  other  eye; 
to  allow  no  infected  dressings  or  solutions  to  stand  about 
where  harm  might  come  from  them,  and  after  each 
handling  of  the  patient's  eye  to  wash  their  hands,  im- 
mediately and  thoroughly,  with  soap  and  water. 

In  adults,  internal  remedies  are  at  times  indicated — 
morphin  to  relieve  severe  pain,  trional  to  control  less 
severe  pain  and  to  induce  sleep,  qumin  in  liberal  doses 
when  necrosis  of  the  cornea  threatens,  or  in  combi- 
nation with  iron  when  the  vitality  of  the  patient  is 
reduced. 

Much  benefit  has  resulted  from  the  prophylactic 
measures  proposed  by  Crede  for  the  prevention  of 
ophthalmia  neonatorum,  and  they  should  be  resorted 
to  in  every  case  in  which  the  mother  is  known  to  have 


l68  PREVALENT    DISEASES    OF    THE    EYE. 

a  specific  vaginitis,  or  in  which  there  is  a  suspicion  that 
such  is  the  case.  These  measures  consist  in  the  syring- 
ing of  the  vagina  for  some  days  previous  to  and  during 
labor  with  a  three  per  cent,  solution  of  carbolic  acid, 
and  in  a  single  careful  application  of  a  two  per  cent, 
solution  of  silver  nitrate  to  the  infant's  eyes  directly 
after  birth  or,  at  least,  as  soon  as  they  have  been  thor- 
oughly cleansed.  Protargol  has  recently  been  substi- 
tuted for  the  silver  nitrate  with  excellent  results.  It 
should  be  used  in  ten  per  cent,  solution,  in  which 
strength  it  is  far  less  irritating  than  the  two  per  cent, 
silver  nitrate  solution  recommended  by  Crede. 

Croupous  or  Membranous  Conjunctivitis. — It 
is  with  some  hesitation  that  this  variety  of  conjunctival 
inflammation  is  described  as  a  distinct  disease,  since 
there  are  excellent  reasons  for  regarding  it  rather  as 
a  type  of  inflammation  prone  to  occur,  under  favoring 
conditions,  in  several  different  kinds  of  conjunctivitis. 
Reference  has  been  made  to  the  fact  that  in  certain 
unfavorable  cases  of  purulent  conjunctivitis,  attended 
by  a  thin,  watery  discharge,  a  membranous  exudation 
tends  to  form  upon  the  palpebral,  and  at  times  upon 
the  bulbar,  conjunctiva;  and  it  may  be  added  that  a 
similar  disposition  occasionally  manifests  itself  in 
catarrhal  conjunctivitis.  A  typical  form  of  mem- 
branous conjunctivitis  is  that  which  is  induced  by  the 
application  of  the  jequirity  bean  in  the  treatment  of 
trachoma.  Rarely,  a  chronic  form  of  croupous  con- 
junctivitis is  met  with,  in  w^hich  the  membrane  forms 
and  re-forms  for  weeks  and  even  months. 

In  true  diphtheria  of  the  conjunctiva  the  membrane 
frequently  forms  upon  the  bulbar  as  well  as  upon  the 
palpebral  conjunctiva;  but  in  the  milder  affection 
under  consideration  the  exudate,  which  does  not  invade 


DISEASES    OF    THE    CONJUNCTIVA.  169 

the  subconjunctival  tissue  as  in  true  diphtheria,  and 
can,  as  a  rule,  be  easily  detached,  is  usually  confined 
to  the  conjunctiva  of  the  lids.  In  croupous  conjunc- 
tivitis the  danger  of  corneal  implication  is  slight;  but 
there  is  commonly  more  pronounced  ciliary  irritation 
and  more  decided  edema  of  the  lids  than  is  found  in 
catarrhal  conjunctivitis.  The  discharge  is  scant  and 
watery.  Usually  after  a  few  days  the  membrane — 
which  consists  of  a  meshwork  of  coagulated  fibrin,  pus 
corpuscles,  and  epithelial  cells — ceases  to  be  formed, 
and  the  case  assumes  the  features  of  a  severe  catarrhal, 
or,  perhaps,  of  a  purulent,  conjunctivitis. 

The  condition  of  the  system  seems  to  have  much 
to  do  in  determining  this  type  of  conjunctival  inflam- 
mation. Unhealthy,  ill-nourished  children — the  sub- 
jects of  inherited  syphilis,  for  example — are  especially 
prone  to  it.  It  may  be  induced  also  by  the  injudicious 
employment  of  too  severe  remedies  in  catarrhal  and 
in  purulent  conjunctivitis,  as,  for  example,  unduly 
strong  solutions  of  silver  nitrate. 

Treatment. — This  should  be  constitutional  as  well 
as  local.  Iron  and  quinin  internally,  and  mild  appli- 
cations to  the  eyes,  are  indicated.  Boracic  acid  (gr. 
x-xv  to  .5j)  is  useful,  as  is  also  a  i  :  8000  solution  of 
corrosive  sublimate.  Atropin  (gr.  j  to  5J)  may  be 
employed  when  there  is  marked  ciliary  irritation. 
After  the  formation  of  the  membrane  has  ceased,  and 
the  discharge,  previously  watery,  has  become  muco- 
purulent, astringents  (zinc,  sulphat.,  gr.  ss;  acid, 
boracic,  gr.  x;  aq.  destil.,  ,5J,  or  protargol  in  two  to 
four  per  cent,  solution)  are  called  for,  but  should  be 
used  with  caution. 

Diphtheritic  Conjunctivitis. — True  diphtheria  of 
the    conjunctiva,    characterized    by    the    presence   of 


170 


PREVALENT    DISEASES    OF    THE     EYE. 


the  Klebs-Loffler  bacillus — to  which  condition  the 
term  "diphtheritic  conjunctivitis"  should  be  restricted 
— is  not  among  the  commoner  diseases  of  the  eye; 
still,  as  it  is  an  affection  which  may  be  encountered 
at  anv  time  by  the  general  practitioner,  a  brief  account 
of  it  seems  to  be  called  for. 

Like  faucial  diphtheria,  diphtheritic  conjunctivitis, 
one  of  the  most  dangerous  diseases  to  which  the  eve 
is  subject,  occurs  more  frequently  in  children  than  in 
adults.     The  onset  of  the  disease  is  sudden,  and  its 


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^ 

Wmr 

•^5J^«5r">i 

A^ 

■■S 

P- 

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1 

Fig.  69. —  Diphtheritic  conjunctivitis  in  a  child  (Haab). 

development  rapid.  Severe  pain  is  experienced,  and 
the  lids  are  not  only  red  and  greatly  swollen,  but, 
owing  to  the  character  of  the  infiltration,  are  tense  and 
brawny  (Fig.  69).  The  discharge  at  first  is  thin, 
ichorous,  and  scanty,  but  at  a  later  stage  frequently 
becomes  purulent.  The  membrane,  which  usually 
forms  upon  the  ocular,  as  well  as  upon  the  palpebral, 
conjunctiva,  is  thick  and  coherent,  gravish  in  color, 
and  extends  so  deeply  into  the  subconjunctival  tissue 
that  it  is  not  possible  to  detach  it  (Fig.  70).  Destruction 
of  the  cornea,  in  consequence  of  the  rapid  and  extensive 


DISEASES    OF    THE    CONJUNCTIVA.  I7I 

infiltration  of  the  bulbar  conjunctiva  interfering  with 
its  nourishment,  is  the  result  which  is  most  to  be 
dreaded.  Deep  sloughs,  involving  not  only  the  con- 
junctiva but  the  subconjunctival  cellular  tissue,  may 
occur,  and  the  contraction  resulting  from  this  destruction 
of  tissue  is  apt  to  produce  entropion  with  its  attendant 
ill  consequences.  The  constitutional  symptoms  which 
are  present  in  faucial  diphtheria — fever,  general  depres- 
sion, etc. — manifest  themselves.  Usually  both  eyes  are 
involved,  though  this  is  not  always  the  case. 


Fig.   70. — Diphtheritic  conJuM^iiMiis  in  a  child  (Haab). 

The  infection  of  the  eye  may  be  direct  and  primary, 
or  it  may  be  secondary  to  diphtheria  of  the  throat  and 
nose,  occurring  as  a  result  of  accidental  inoculation  or 
of  extension  through  the  lacrimal  passages.  Occa- 
sionally the  disease  manifests  itself  after  operative 
procedures  upon  the  eye.  Atypical  examples  of  diph- 
theritic conjunctivitis  have  been  observed,  in  which 
the  brawny  infiltration  of  the  lids  and  the  conjunctival 
false  membrane  are  absent,  and  yet  rapid  destruction 
of  the  cornea  occurs,  and  the  Klebs-Loffler  bacillus 
is  found  to  be  present  (Fig.  71). 


172  PREVALENT    DISEASES    OF    THE    EYE. 

Treatment. — The  most  important  therapeutic  meas- 
ure, as  in  the  faucial  type  of  the  disease,  is  the  injection 
of  the  diphtheria  antitoxin.  The  results  of  this  plan 
of  treatment  have  been  most  gratifving,  and,  as  Jackson 
expresses  it,  "its  importance  overshadows  that  of  all 
local  remedies."  Quinin,  iron,  stimulants,  and  a 
nutritious  diet  are  also  indicated.  The  local  treatment 
consists  in  the  application  of  warm  fomentations,  the 
lotion  of  opium  and  boracic  acid  (ext.  opii,  gr.  x;   acid. 


Fig.  71. — Bacillus  diphtherias,  from  a  culture  upon  blood-serum;   X    1000 
(Frankel  and  Pfeiffer). 

boracic,  gr.  xl;  aq.  destil.,  .^iv)  being  one  of  the  best, 
and,  for  direct  application  to  the  eye,  mild  antiseptic 
rather  than  caustic  or  astringent  solutions.  Among 
these  boracic  acid,  in  saturated  solution,  and  bichlorid 
of  mercury  (i  :  8000)  are,  perhaps,  the  most  useful. 
A  two  per  cent,  solution  of  potassium  permanganate 
is  also  recommended. 

When  the  disease  is  limited  to  one   eve,   the    same 
precautions  should  be  taken  as    in  purulent  conjunc- 


DISEASES    OF    THE    CONJUNCTIVA.  1 73 

tivitis  to  prevent  inoculation  of  the  fellow-eve.  Those 
in  attendance  should  also  be  warned  of  the  danger  of 
inoculating  their  own  ocular  or  faucial  mucous  mem- 
brane. During  the  declining  stage  of  the  disease,  when 
the  membrane  has  been  thrown  off,  and  the  discharge 
has  become  purulent,  protargol  in  ten  per  cent.,  or 
silver  nitrate  in  one  per  cent.,  solution  may  be  employed 
with  advantage. 

Follicular  Conjunctivitis. — The  seat  of  this  affec- 
tion is  chiefly  in  the  palpebral  conjunctiva  and  in  the 
retrotarsal  folds,  though  more  or  less  pronounced  hyper- 
emia of  the  bulbar  conjunctiva  is  often  observed.  Its 
characteristic  feature  is  the  presence  of  enlarged  folli- 
cles— hypertrophied  lymphoid  tissue — in  the  superior 
and  inferior  retrotarsal  folds.  In  well-marked  cases 
it  bears  a  close  resemblance  to  the  follicular  type 
of  trachomatous  conjunctivitis;  but  the  hypertrophied 
papillae  observed  in  this  disease  are  not  present,  the 
enlarged  follicles  are  more  definitely  limited  to  the  retro- 
\  tarsal  folds,  and  it  does  not  lead  to  pannus  or  deform- 
ity of  the  lids.  It  is  at  times,  however,  an  obstinate 
affection,  and  not  infrequently  shows  but  little  disposi- 
tion to  respond  to  treatment.  It  is  an  interesting  fact 
that  the  negro  race,  which  is  almost  immune  from  tra- 
chomatous conjunctivitis,  is  especially  prone  to  this 
variety  of  conjunctival  inflammation.  It  is  probably  of 
microbic  origin,  but  this  has  not  been  demonstrated.  It 
is  attended  by  a  slight,  mucous  discharge,  by  a  feeling 
as  though  dust  were  in  the  eyes,  and  sometimes  by 
itching. 

Treatment. — A  collyrium  of  corrosive  sublimate 
(i  :  12,000  to  I  :  8000)  with  sodium  chlorid  (one  per 
cent.)  is  the  remedy  which  I  have  found  most  useful. 
Zinc  sulphate   and   boracic   acid,   as   recommended  in 


174  PREVALENT    DISEASES    OF    THE    EYE. 

catarrhal  conjunctivitis,  and  protargol  (in  two  to  five  per 
cent,  solution)  I  have  also  employed  with  good  effect. 

Trachomatous  or  Granular  Conjunctivitis 
(Granular  Lids). — The  distinctive  characteristics  of 
this  variety  of  conjunctivitis,  which  expends  its  force 
chiefly  upon  that  portion  of  the  conjunctiva  which 
lines  the  lids  and  constitutes  the  retrotarsal  folds, 
are  its  chronicity,  the  marked  structural  changes 
which  it  causes  not  only  in  the  conjunctiva  but  in  the 
subconjunctival  tissue  as  well,  and  the  secondary 
changes,  known  as  pannus,  which  it  induces  in  the 
cornea. 

Its  pathology  is  as  yet  but  imperfectly  understood; 
but  it  is,  without  doubt,  a  contagious  disease,  the  pro- 
duct of  a  specific  organism.  A  small  diplococcus, 
first  described  by  Sattler,  is  held  by  some  to  be  the 
organism  which  produces  it,  but  this  has  not  been 
conclusively  shown. 

Although  one  of  the  most  intractable  diseases  of  the 
eye  with  which  we  have  to  deal,  and  in  its  ultimate 
consequences  as  disastrous  to  sight  as  any,  trachoma- 
tous conjunctivitis  does  not,  like  purulent  conjunc- 
tivitis, threaten  the  eye  with  immediate  destruction. 
The  inflammation  does  not  approach  in  intensity  that 
which  characterizes  the  latter  disease;  nevertheless, 
during  the  acute  stage  which  supervenes  upon  inocu- 
lation, there  is  usually  marked  conjunctival  injection, 
with  considerable  swelling  of  the  lids,  and  pronounced 
I  photophobia,  lacrimation,  and  blepharospasm.  The 
discharge,  which  is  not  abundant,  is  mucoid  or  muco- 
purulent in  character.  The  first  evidences  of  corneal 
implication,  a  slight  roughening  of  the  external  epi- 
thelial layer,  may  become  manifest  within  a  few  weeks 
of  the  onset  of  the  attack. 


DISEASES    OF    THE    CONJUNCTIVA. 


175 


With  the  subsidence  of  the  more  acute  symptoms  the 
chronic  stage  of  the  disease  begins,  and  this,  if  left  to 
itself,  may  last  a  lifetime,  rendering  existence  miserable, 
and  reducing  the  individual  to  a  state  of  helplessness 
and  dependence;  for  not  only  is  the  sight  greatly  im- 
paired, as  a  result  of  the  corneal  changes,  but  the  eyes 
(for  both  eyes  are  commonly  involved,  though  exceptions 
to  this  rule  are  encountered)  are  persistently  irritable 


Fig.  72. — Section  of  a  trachoma  follicle  from  the  retrotarsal  fold. 
Magnified  24  X  i  (Fuchs).  The  trachomatous  granulation,  T,  pushes 
up  the  conjunctiva  in  the  form  of  an  elevation,  and  is  inclosed  by  a  layer 
of  thickened  connective  tissue,  the  capsule,  k.  The  conjunctiva  is  in- 
filtrated with  cells,  both  in  its  upper  layers,  a,  and  along  the  vessels,  g\ 
the  epithelium,  e,  shows,  above  the  place  marked  a,  bright  spots  which 
correspond  to  the  goblet  cells;  at  d,  it  lines  one  of  Henle's  glands. 


and  photophobic,  and  lacrimation  and  blepharospasm 
are  generally  present. 

It  is  usual  to  describe  two  varieties  of  the  disease — 
a  papillary  and  a  follicular.  In  the  former  the  dis- 
tinctive feature  is  hypertrophy  of  the  papillae  of  the 
tarsal  conjunctiva  (Plate  III,  Fig.  3);  in  the  latter,  the 
presence  in  the  conjunctiva  of  the  tarsus  and  in  the  retro- 
tarsal folds  of  the  so-called  "trachoma  granules"  or 
''trachoma  follicles."  More  often  the  affection  is  of  a 
mixed  type,  both  of  these  features  being  present.     The 


176 


PREVALENT    DISEASES    OF    THE     EYE. 


trachoma  follicles,  which  are  made  conspicuous  by 
everting  the  lids  and  causing  the  retrotarsal  folds  to 
protrude,  are  translucent  bodies,  having  a  resemblance 
to  boiled  sago  grains  or  frog's  spawn.  Recent  investi- 
gation seems  to  show  that  they  are,  in  fact,  hypertro- 
phied  lymphoid  and  connective-tissue  cells,  enclosed  in 
a  fibrous  envelope  (Fig.  72).  The  hypertrophy  of  the 
papillae  of  the  tarsal  conjunctiva,  which  is  observable 


Fig-  73- — Cross-section  through  the  trachomatous  conjunctiva  of 
the  upper  lid.  Magnified  24  X  i  (Fuchs).  Both  small  papillae,  P,  P, 
and  large  ones,  Pj,  Pj,  are  found.  The  former  stand  side  by  side  like 
the  pickets  of  a  palisade;  the  depressions,  /,  t,  lying  between  them  and 
coated  with  epithelium,  look  like  the  tubules  of  glands.  The  large  pa- 
pillae contain  trachoma  granules,  T,  T^,  which  are  not  sharply  limited 
and  do  not  possess  a  capsule.  The  epithelium  of  the  conjunctiva  is  in  many 
places,  e,  e,  thickened.  The  mucous  coat  is  in  a  condition  of  cellular  in- 
filtration, which  is  especially  marked  in  the  vicinity  of  the  blood-vessels, 


chiefly  upon  the  upper  lid  (Fig.  J^),  and  the  develop- 
ment of  the  trachoma  follicles  are  accompanied  by 
pronounced  hyperplasia  of  the  submucous  connective 
tissue. 

Ultimately  there  supervenes  a  stage  of  atrophy  (Fig. 
74),  which  in  the  worst  cases  results  in  the  condition 
known  as  xerophthalmia,  in  which  the  conjunctiva — 
itself  so  atrophied  that  the  retrotarsal  folds  are  obliter- 


DISEASES    OF    THE    CONJUNCTIVA. 


^n 


ated,  and  free  movements  of  the  lids  and  eyeball  cur- 
tailed— loses  the  character  of  a  mucous  membrane,  and 
becomes  dry  and  cuticular,  while  the  cornea  becomes  so 
opaque  that  vision  is  reduced  to  little  better  than  light 
perception.  A  more  common  consequence  of  this  atro- 
phic process  and  of  the  contraction  which  accompanies 
it,  is  the  development  of  entropion  (Fig.  75),  that  very 
annoying  condition  in  which  the  lid-margins  are  in- 
verted, and  the  eyelashes   come  in  contact  with,  and 


Fig.   74. —  Cicatricial  stage  of  trachoma  with  pannus   (Hansell  and  Sweet). 


constantly  irritate,  the  bulbar  conjunctiva  and  the 
cornea.  (See  Chapter  upon  Diseases  of  the  Eyelids 
and  Orbit.) 

The  secondary  changes  which  occur  in  the  cornea, 
it  seems  probable,  are  largely  due  to  the  mechanical 
violence  to  which  it  is  subjected  through  constant  fric- 
tion with  the  roughened  inner  surface  of  the  lids.  At 
first  the  cornea  shows  a  mere  loss  of  luster,  a  slight 
roughening  of  its  surface;  but  soon  it  becomes  more 
decidedly    opaque;     numerous    blood-vessels    develop 


178 


PREVALENT    DISEASES    OF    THE    EYE. 


upon  it;    its  surface  becomes  uneven;    and  from  time 
to  time  sluggish  ulcers  make  their  appearance — these 


Fig.  75.— Schematic  section  through  the  lids  and  eyeball  {A,  in  recent^ 
B,  in  old  trachoma)  (Fuchs).  A  shows  the  way  in  which  the  two  forms 
of  hypertrophy  of  the  conjunctiva  are  distributed  among  the  separate  divi- 
sions of  the  latter;  B,  the  stage  of  sequelae  of  trachoma,  s,  s-^,  eyebrows;. 
0,  Oi,  furrow  between  the  brow  and  the  lid  (sulcus  orbito-palpebralis) ;  d, 
di,  covering  fold;  c,  cilia  in  their  proper  position;  Cj,  cilia  turned  toward 
the  cornea;  ;-,  free  border  of  the  lid,  with  the  borders  of  the  upper  and 
lower  lids  running  parallel  and  the  posterior  margins  of  the  lids  acute; 
rj,  free  border  of  the  lid,  looking  backward,  and  with  its  posterior  margin 
rounded;  t,  tarsus  thickened  by  infiltration  and  covered  with  the  velvety 
conjunctiva  tarsi;  t^,  tarsus  thinned  (atrophic),  bent  at  an  angle  near  its 
free  extremity,  and  covered  with  smooth  epithelium;  /,  fornix  with  nu- 
merous trachoma  granulations,  T,  in  the  folds  of  the  conjunctiva;  /,, 
fornix  smooth,  without  folds  (symblepharon  posterius);  p,  thick  pannus 
covering  the  upper  half  of  the  cornea;  p^,  a  shrunken  pannus,  extending 
over  the  whole  cornea. 


changes  being  more  marked  upon  the  upper  half  of  the 
cornea,  because  here  the  lid  friction  is  greatest. 

Although,    as    has    been    stated,    unquestionably    a 
contagious    disease,    the    contagium    which    gives    rise 


DISEASES    OF    THE    CONJUNCTIVA.  I79 

to  trachomatous  conjunctivitis,  fortunately,  is  non- 
volatile, and  so  the  disease  can  be  communicated  only 
by  actual  transference  of  the  discharge  from  one  eye 
to  another.  This  commonly  occurs  through  the 
medium  of  towels,  handkerchiefs  and  the  like,  and 
it  is  for  this  reason  that  the  affection  so  often  flourishes 
in  orphan  asylums,  reformatories,  workhouses,  etc. 

Filth,  unhygienic  surroundings,  uncleanly  habits, 
and  ill-nourishing  food  unquestionably  favor  the  de- 
velopment and  spread  of  this  loathsome  malady;  but 
the  view,  not  infrequently  expressed,  that  trachoma 
may  actually  originate  from  such  conditions,  may  de- 
velop without  a  pre-existent  case  to  supply  the  con- 
tagium,  is,  it  seems  to  me,  absurd;  as  absurd,  indeed, 
as  to  suppose  that  smallpox  or  cholera  might  originate 
in  similar  fashion.  It  is  a  fact  of  interest  that  certain 
races,  the  Jews  and  the  Irish,  for  example,  exhibit  an 
especial  predisposition  to  the  disease,  while,  on  the 
other  hand,  the  negro  is  practically  immune  from  it. 

In  the  early  stages  of  trachomatous  conjunctivitis 
it  is  not  always  possible  to  reach  a  definite  diagnosis; 
for  there  are  less  severe  forms  of  conjunctival  inflamma- 
tion, more  especially  follicular  conjunctivitis,  in  which 
hypertrophy  of  the  palpebral  lymphoid  tissue  and 
frog-spawn-like  follicles  are  observed.  However,  the 
behavior  of  the  case  under  treatment,  and  especially  the 
occurrence  of  pannitic  corneal  changes,  soon  establish 
the  true  nature  of  the  afl^ection.  In  the  chronic  stage 
of  the  disease  the  distinctive  features  are  pannus  (Figs. 
74  and  76),  more  or  less  evident  entropion,  and  the 
presence  of  irregular,  linear  scars  upon  the  conjunctival 
surface  of  the  upper  lid. 

Treatment. —The  treatment  of  this  aflPection  yields 
far   from   satisfactory   results,    and   even   in   the   most 


i8o 


PREVALENT    DISEASES    OF    THE     EYE. 


favorable  cases  must  be  long-continued  to  be  effective. 
Moreover,  relapses  are  of  common  occurrence,  and,  for 
this  reason,  it  is  well  to  give  a  guarded  prognosis  as  to 
the  future.  Silver  nitrate  (in  two  to  four  per  cent, 
solution)  in  the  earlier  stages,  and  copper  sulphate  (in 
the  form  of  a  crystal,  applied  to  the  everted  lids)  at 
a  later  stage,  are  the  remedies  which  formerly  were 
chiefly  relied  upon,  and  which  are  still  extensivelv 
used.     However,  recent  experience  has  led  me  to  the 


Fig.  76. —  Cross-section  through  the  margin  of  a  cornea  affected  with 
pannus.  Magnified  125  X  i  (Fuchs).  Beneath  the  epithelium,  E,  E, 
is  the  limbus,  L,  greatly  thickened  by  cellular  infiltration ;  from  it  the  pan- 
nus, P,  in  which  are  perceived  the  cross-sections  of  several  vessels,  extends 
between  the  epithelium  and  Bowman's  membrane,  B,  over  the  cornea,  C. 
S,  sclera. 


conclusion  that  in  trachomatous,  as  in  purulent  con- 
junctivitis, protargol  may  be  employed  with  advantage 
as  a  substitute  for  the  silver  nitrate.  I  am  also  in- 
clined to  believe  that  it  accomplishes  as  much  in  the 
chronic  stage  of  the  disease  as  any  other  remedy,  and 
so  I  find  myself  using  it  instead  of  the  copper  sulphate, 
the  application  of  which  is  so  much  more  painful. 

My  practice,  in  the  acute  as  well  as  in  the  chronic 
stage  of  the  disease,  is  to  apply  to  the  everted  lids, 
every  other  day,  a  forty  per  cent,  solution  of  protargol. 


DISEASES    OF    THE    CONJUNCTIVA. 


I«I 


and  to  prescribe  a  weaker  solution  (ten  to  twenty  per 
cent.)  for  application  by  the  patient  twice  daily.  If 
he  can  be  taught  to  evert  the  lids,  and  make  the  appli- 
cation directly  to  their  inner  surfaces,  this  is  distinctly 
advantageous;  but,  if  this  is  not  practicable,  the  solu- 
tion is  applied  by  means  of  an  eye-dropper.  When 
corneal  ulcers,  attended,  as  they  usually  are,  by  photo- 
phobia, are  present,  the  protargol  treatment  is  sup- 
plemented by  the  instillation,  three  times  a  day,  of  a 
two-  to  four-grain  solution  of  atropin  or  a  one-  to  two- 
grain  solution  of  holocain.  The  other  remedial  meas- 
ure chiefly  relied  upon  is  the  use  of  the  roller  forceps 
of  Knapp  (Fig.  77).  This  treatment  has  been  found 
especially  useful  in  the  follicular  type  of  the  disease, 


Fig-   77- — Knapp's  roller-forceps. 

the  forceps  being  employed,  from  time  to  time,  to 
squeeze  out  any  "trachoma  follicles"  which  may  be 
discovered  in  the  tarsal  conjunctiva  or  in  the  retrotarsal 
folds.  To  lessen  the  considerable  pain  which  attends 
this  procedure,  the  eye  should  be  brought  well  under 
the  influence  of  cocain.  The  lid  is  then  everted,  and 
the  forceps  are  made  to  grasp  the  everted  cartilage  or 
the  retrotarsal  folds  of  the  conjunctiva,  and  the  follicles 
are  expressed  by  gentle  traction,  combined  with  not- 
too-firm  compression  of  the  blades  (Fig.  78). 

Should  the  condition  of  the  eyes  not  improve  under 
the  use  of  protargol,  silver  nitrate  in  two  per  cent, 
solution,  or  the  crystal  of  copper  sulphate,  to  be  applied 
not  oftener  than  every  other  day,  should  be  tried  instead, 
or  a  crystal  of  alum,  which  the  patient  may  apply  to 


1 82 


PREVALENT    DISEASES    OF    THE     EYE. 


the  everted  lids  two  or  three  times  a  day,  and  which 
sometimes  is  very  beneficial,  may  be  prescribed.  A 
five  per  cent,  ointment  of  copper  citrate,  to  be  applied 
two  or  three  times  a  day,  is  one  of  the  newer  remedies 
claimed  to  be  useful  in  this  condition.     When  entropion 


Fig.   78. —  Expression    of   trachoma    follicles    with   Knapp's    roller   forceps 
(Hansell  and  Sweet). 

is  present,  removal  of  the  inverted  lashes  affords  tem- 
porary relief  (Fig.  79).  To  secure  permanent  relief  the 
lid-fault  must  be  corrected  by  operative  procedure  (see 
Chapter  III). 

In  cases  which  exhibit  marked  pannus,  with  a  plenti- 


DISEASES     OF    THE    CONJUNCTIVA.  183 

ful  supply  of  blood-vessels  upon  the  cornea,  much  may 
be  accomplished  by  the  jequirity  treatment;  but  the 
risk  of  serious  corneal  complications  attending  the  use 
of  this  remedy  is  so  considerable,  that  one  hardly  feels 
warranted  in  recommending  its  employment  by  the 
general  practitioner. 

Vernal  Conjunctivitis  or  Spring  Catarrh. — This 
very  obstinate  form  of  conjunctival  inflammation  is 
met  with  chiefly  in  children.  It  usually  attacks  both 
eyes,  and  is  probably  mildly  contagious.  It  derives 
its  name  from  the  fact  that  the  disease  remains  com- 
paratively dormant  during  the  winter,  and  becomes 
more  active  and  troublesome  with  the  oncoming  of 
warm    weather.     Though    probably    dependent    upon 


Fig.   79. —  Epilation-forceps. 

a  specific  germ,  the  eff^orts  to  discover  this  have  so  far 
proved  fruitless. 

Two  types  of  the  disease  are  met  with.  In  one,  the 
bulbar  conjunctiva  is  the  seat  of  the  characteristic 
changes;  in  the  other,  they  are  found  in  the  conjunctiva 
of  the  tarsus.  Well-marked  examples  of  the  two  types 
are  rarely  met  with  in  the  same  individual;  at  least, 
this  has  been  my  experience.  In  the  bulbar  variety 
(Fig.  80)  there  is  observed  a  slightly  elevated,  nodular, 
gelatinous  growth,  of  yellowish-brown  color,  upon  the 
conjunctiva,  close  to  the  corneal  border.  In  some  in- 
stances this  growth  exhibits  a  tendency  to  encircle  the 
cornea,  as  a  rather  narrow  band;  in  others  it  tends  to 
spread  upon  the  conjunctiva,  especially  in  the  direction 
of  the  inner  and  outer  canthi,  and,  to  a  less  extent, 


184  PREVALENT    DISEASES    OF    THE     EYE. 

upon  the  cornea.  In  rare  cases  the  whole  cornea  is 
overrun,  and  the  sight  in  consequence  is  greatly  im- 
paired. The  nodular  masses,  which  are  stable  and 
show  no  disposition  to  ulcerate,  are  composed  of 
connective  tissue  and  greatly  thickened  epithelium, 
the  latter  showing  a  tendency  to  extend  into  the  under- 
lying tissue  in  the  form  of  solid  epithelial  plugs  (Fuchs). 
In  the  palpebral  variety  the  papillae  of  the  tarsal 
conjunctiva,    and    to    a    less    extent   those  of  the  re- 


Fig.  80. —  Vernal  con-  Fig.  Si. —  \'ernal  conjunctivitis,  showing  typ- 

junctivitis  (bulbar  type)  ical  palpebral  as  well  as  bulbar  changes  (Dr. 

(Haab).  Wm.  Zentmayer's  case)  (Hansell  and  Sweet). 


trotarsal  folds,  undergo  a  peculiar  hypertrophy,  and 
at  the  same  time  become  flattened  (probably  from  the 
constant  pressure  to  which  they  are  subjected),  so 
that  the  inner  surface  of  the  lid  (it  is  the  upper  lid 
which  commonly  exhibits  these  changes)  presents  a 
strikingly  tessellated  appearance.  The  hypertrophied 
papillae  (admirably  shown  in  the  accompanying  illus- 
tration. Fig.  81)  are  as  firm  almost  as  cartilage,  and 
their  edges,  which  overhang  in  mushroom-like  fashion. 


DISEASES    OF    THE    CONJUNCTIVA.  185 

can  be  slightly  elevated.  According  to  Fuchs,  they  are 
composed  of  areolar  connective  tissue,  with  connective- 
tissue  cells  which  have  undergone  a  peculiar  hyaline 
degeneration,  and  are  covered  by  thickened  epithelium, 
which  gives  to  the  conjunctival  surface  of  the  lid  the 
bluish-white,  skimmed-milk  appearance  that  is  a  fea- 
ture of  the  disease. 

The  most  prominent  symptom  of  vernal  catarrh  is  per-  1 
sistent  itching.  Pain  is  not  complained  of,  but  rather 
a  sensation  of  sand  being  in  the  eyes.  The  discharge 
is  slight.  Not  infrequently  the  disease  lasts  for  years, 
and  rarely  is  it  of  brief  duration.  It  is  not  uncommon 
to  meet  with  more  than  one  case  in  members  of  the 
same  family.  For  instance,  the  author  has  encountered 
marked  examples  of  the  palpebral  variety  in  a  father 
and  his  two  sons,  and  also  in  sisters  who  were  twins. 

Treatment. — As  a  rule,  the  disease,  especially  when 
it  is  well  marked,  responds  to  treatment  very  unsatis- 
factorily. The  remedy  which  has  yielded  me  the  best 
results  is  bichlorid  of  mercury.  This  is  prescribed  as 
a  collyrium,  in  the  strength  of  i  :  8000,  with  the  addition 
of  one  per  cent,  sodium  chlorid,  and  is  dropped  into 
the  eyes  three  times  a  day.  To  be  effective  the  remedy 
must  be  long  continued,  although  in  the  milder  cases 
improvement  may  manifest  itself  within  two  or  three 
weeks;  in  the  more  severe  cases  it  is  a  matter  of  months 
rather  than  weeks.  Other  remedies  which  may  be 
tried  are  zinc  sulphate  and  boracic  acid,  as  recom- 
mended in  catarrhal  conjunctivitis;  yellow  oxid  of  mer- 
cury ointment  (hydrarg.  ox.  flav.,  gr.  j;  vaselin,  oj), 
to  be  applied  to  the  eye  once  a  day;  dilute  acetic  acid 
(i  part  of  the  dilute  acid  to  250  parts  of  water),  to  be 
dropped  into  the  eye  three  times  a  day,  as  recommended 
by  Van   Millingen,   and   salicylic   acid   ointment,  two 


150  PREVALENT    DISEASES    OF    THE     EYE. 

to  fifteen  per  cent.,  as  suggested  by  Randolph.  The 
internal  administration  of  syrup  of  iodid  of  iron  has 
seemed  to  me,  at  times,  to  be  of  benefit,  and  in  the 
palpebral  type  of  the  disease  I  have  thought  that  good 
resulted  from  the  use  of  the  roller  forceps,  employed 
as  in  trachoma. 

Phlyctenular  or  Scrofulous  Conjunctivitis. — 
The  essential  feature  of  this  form  of  conjunctivitis, 
which  is  known  also  as  conjunctivitis  lymphatica  and 
as  eczema  conjunctives,  is  its  dependence  upon  a  con- 
stitutional cause.  Though  not  infrequently  met  with 
in  adults,  it  is  a  disease  to  which  children  are  especially 
disposed.  It  happens  as  often  that  both  eyes  are 
affected  as  that  one  only  is  involved. 

In  the  typical  form  of  the  disease  the  conjunctival 
injection  is  not  uniform,  but  is  more  marked  in,  or, 
perhaps,  is  confined  to,  the  neighborhood  of  the  phlyc- 
tenulae  (Plate  IV,  Fig.  i).  These  are  yellowish-red 
elevations,  differing  in  size  from  that  of  a  mustard-seed 
to  a  small  split  pea,  and  composed  chiefly  of  lymphoid 
cells,  which,  in  varying  numbers, — usually  two  or  three, 
— develop  upon  the  ocular  conjunctiva,  more  especially 
in  the  neighborhood  of  the  corneal  border,  and  are  con- 
verted quickly  into  superficial  ulcers  through  loss  of 
their  epithelial  covering.  Pain  is  not  a  symptom  of  the 
disease,  but  photophobia  and  lacrimation  are  frequently 
present.  The  discharge  is  mucoid,  and  is  less  abundant 
than  in  catarrhal  conjunctivitis.  The  affection  is  not 
contagious. 

As  often  as  not  the  phlyctenulae  make  their  appear- 
ance upon  the  cornea  as  well  as  upon  the  conjunctiva, 
and  then  the  affection  is  known  as  phlyctenular  kerato- 
conjunctivitis. Under  such  circumstances  the  photo- 
phobia is  apt  to  be  more  pronounced — in  some  instances 


PLATE  IV. 


-        ^^»<v^ ^,. 


K 


Fig.   I. — Phlyctenular  Conjunctivitis. 


i^<  o  U  u; 

Fig.  2. — Pterygium. 


DISEASES    OF    THE    CONJUNCTIVA.  187 

intense — and  to  be  attended  by  blepharospasm  and 
profuse  lacrimation.  It  is  through  involvement  of  the 
cornea  that  the  disease,  at  times,  permanently  and 
seriously  damages  the  eye.  In  consequence,  usually, 
of  neglect  or  of  injudicious  treatment,  the  corneal 
ulcers  left  by  the  breaking-down  of  the  phlyctenulae 
extend  laterally  and  in  depth  until,  perhaps,  a  perfora- 
tion into  the  anterior  chamber  occurs  or,  at  all  events, 
until  the  cornea  is  seriously  damaged.  A  leucoma,  or 
dense  opacity  of  the  cornea,  results,  which,  if  central 
or  nearly  central,  greatly  impairs  the  sight.  More  than 
this,  if  the  ulcer  perforates  into  the  anterior  chamber, 
a  permanent  adhesion  of  the  iris  to  the  cornea  at  the 
point  of  perforation  is  almost  sure  to  occur,  and  this 
is  usually  attended  by  distortion  and  displacement  of 
the  pupil  (see  Fig.  lOo). 

When  phlyctenular  conjunctivitis  presents  the  typical 
appearance  which  has  been  described,  it  is  not  difficult 
of  recognition.  Occasionally,  however,  in  what  may 
be  properly  termed  the  catarrhal  type  of  the  disease, 
the  conjunctival  injection  is  diffuse,  and  the  phlyctenular 
are  absent  or  not  distinguishable.  Under  such  cir- 
cumstances the  eye  presents  almost  the  same  appear- 
ance that  it  does  in  acute  catarrhal  conjunctivitis,  with 
which  it  may  be  confounded,  if  only  the  condition  of 
the  conjunctiva  is  relied  upon  as  a  diagnostic  guide. 
However,  in  true  catarrhal  conjunctivitis  both  eyes 
are  almost  invariably  affected,  and  there  are  no  evi- 
dences of  constitutional  derangement,  whereas,  in 
phlyctenular  conjunctivitis,  as  has  been  pointed  out, 
it  often  happens  that  only  one  eye  is  involved,  and 
it  is  seldom  the  case  that  there  are  not  present  other 
evidences  of  constitutional  disorder,  such  as  blepharitis 
marginalis,  eczema  of  the  face,  etc.     As  the  treatment 


l88  PREVALENT    DISEASES    OF    THE    EYE. 

called  for  in  catarrhal  conjunctivitis  (the  use  of  an 
astringent  collyrium)  is  sure  to  be  harmful  in  phlycten- 
ular conjunctivitis,  it  is  most  important  that  the  two 
conditions  should  not  be  confounded.  It  may  be 
added,  that  when  the  diagnosis  is  in  doubt,  especially 
in  dealing  with  children,  it  is  safer  to  treat  the  case  as 
one  of  strumous  character. 

The  name  "scrofulous  conjunctivitis,"  or  "scrofulous 
ophthalmia,"  as  applied  to  the  affection  under  con- 
sideration is  somewhat  misleading;  for,  though  dis- 
tinctlv  scrofulous  individuals  show  an  especial  pre- 
disposition to  the  disease,  it  is  often  met  with  in  persons 
who  can  not  properly  be  regarded  as  belonging  to  this 
category.  This  is  particularlv  true  of  the  cases  which 
are  so  often  encountered  in  children.  Here  the  ocular 
affection,  which  is  frequently  accompanied  by  nasal 
catarrh,  and  by  eczema  of  the  lids,  the  upper  lip,  and 
the  auricle,  and  not  uncommonly  by  suppurative  in- 
flammation of  the  middle  ear,  seems  to  be  largely 
dependent  upon  disorder  of  the  digestive  apparatus, 
brought  about  by  improper  feeding,  by  unhygienic 
surroundings,  and  by  lack  of  pure  air  and  sunlight. 
A  furred  tongue,  "feverish"  breath,  loss  of  appetite, 
and  constipation  of  the  bowels  are  other  symptoms 
which  are  often  present. 

That  in  these  cases  we  have  to  do  with  a  relatively 
mild  form  of  septicemia,  due  in  all  probability  to  the 
entrance  into  the  circulation  of  bacteria  or  their  toxins 
from  the  alimentary  canal,  is  a  view  w^hich  I  have  long 
held,  and  which  I  have  advanced  upon  more  than  one 
occasion.  This  view  seems  to  be  supported  not  only 
bv  the  clinical  features  of  these  cases,  which  are  just 
such  as  might  result  from  the  presence  in  the  blood  of 
a  relatively  benign  septic  organism  ("intestinal  intoxi- 


DISEASES    OF    THE    CONJUNCTIVA.  189 

cation"  is  the  way  it  is  expressed  nowadays),  but  also 
by  the  character  of  the  treatment  which  proves  most 
effective.  For  of  all  remedial  measures  none  produces 
so  prompt  and  decided  a  change  for  the  better — not 
only  in  the  condition  of  the  eye  but  in  the  patient's 
general  condition — as  the  administration  of  a  generous, 
old-fashioned,  calomel  purge,  which  gives  the  '^ prima 
vice"  a  thorough  cleansing.  In  this  connection  it  may 
be  mentioned  that  careful  bacterial  investigations,  made 
by  Weeks  and  others,  show  that  the  Staphylococcus 
aureus  is  commonly  present  in  the  phlyctenulae,  as  it  is 
in  the  eczematous  nodules  which,  as  has  been  stated, 
are  so  often  found  in  association  with  strumous  con- 
junctivitis. 

Treatment. — There  are  few  diseases  of  the  eye  that 
respond  to  treatment  so  promptly  and  satisfactorily 
as  does  phlyctenular  conjunctivitis;  but,  on  the  other 
hand,  there  are  few  in  which  injudicious  treatment 
does  more  harm.  Astringents — silver  nitrate,  zinc 
sulphate,  etc. — are  distinctly  contraindicated,  and  when 
used  invariably  make  matters  worse.  It  goes  without 
saying,  that  the  treatment  of  this  affection,  in  view  of 
its  systemic  origin,  should  be  both  constitutional  and 
local. 

The  local  treatment,  which  is  so  invariably  effectual 
that  it  need  scarcely  ever  be  departed  from,  may  be 
described  in  a  few  words.  It  consists  in  the  applica- 
tion to  the  eye,  three  times  a  day,  of  a  solution  of 
atropin  and  boracic  acid,  and  once  a  day  (preferably 
in  the  morning,  after  the  atropin  has  been  instilled) 
of  an  ointment  of  yellow  oxid  of  mercury  and  vaselin 
(hydrarg.  ox.  flav.,  gr.  j;  vaselin,  5j).  The  exact 
quantity  of  the  ointment  to  be  applied  is  a  matter  of 
little  moment,  but  a  bit  the  size  of  a  match-head  is 


IQO  PREVALENT    DISEASES    OF    THE     EYE. 

sufficient.  It  should  be  carefully  inserted  between  the 
upper  or  lower  lid  and  the  eyeball.  This  may  be  done 
conveniently  with  the  broad  end  of  a  wooden  tooth- 
pick (see  Fig.  9),  or,  more  safely,  if  the  treatment  is 
to  be  carried  out  by  untrained  hands,  with  a  small 
camel's-hair  brush.  If  blepharitis  is  present,  or  eczema 
of  the  lids,  some  of  the  same  ointment  (or,  still  better, 
an  ointment  of  twice  the  strength  mentioned,  and  hav- 
ing "vaselin  cerate"  rather  than  vaselin  as  a  base,  be- 
cause of  its  higher  melting-point)  should  be  applied  to 
the  lids  at  bedtime. 

The  strength  of  the  atropin  solution  prescribed  should 
vary  with  the  degree  of  photophobia,  lacrimation,  and 
blepharospasm  present.  When  the  inflammation  is 
confined  to  the  conjunctiva,  and  there  are  no  phlyc- 
tenulae  upon  the  cornea,  and  when,  therefore,  as  a 
rule,  there  is  but  little  photophobia,  a  one-grain- 
to-the-ounce  solution  of  atropin,  with  ten  grains  of 
boracic  acid,  should  be  ordered.  In  most  cases 
of  kerato-conjunctivitis,  especially  those  occurring  in 
children,  this  same  strength  suffices;  but  the  atro- 
pin should  be  increased  to  two,  or  even  to  tour 
grains,  to  the  ounce,  if  photophobia  and  lacrimation 
are  pronounced.*  Exceptionally,  in  mild  cases,  in 
which  the  conjunctiva  only  is  involved,  and  in  which 
the  effect  of  the  atropin  upon  the  sight  would  cause 
considerable  inconvenience,  it  is  permissible  to  try  a 
collyrium  simply  of  boracic  acid  (ten  to  twelve  grains 
to  the  ounce)  in  connection  with  the  yellow  oxid  of 
mercury  ointment;    but  my  experience  is  that,  almost 

*  Whenever  atropin  is  prescribed,  the  effect  it  will  have  upon  the 
pupil  and  upon  the  sight,  and  the  fact  that  it  is  very  poisonous,  should 
always  be  impressed  upon  the  patient  or  upon  those  in  whose  charge 
he  is. 


DISEASES    OF    THE    CONJUNCTIVA.  IQI 

without  exception,  the  cases  do  better,  and  the  affection 
yields  much  more  promptly,  when  atropin  is  employed. 

For  the  effectual  application  of  the  atropin  solution 
an  eye-dropper  is  indispensable,  and  even  with  its 
aid,  owing  to  the  spasm  of  the  lids,  this  is  not  always 
easy  of  accomplishment.  The  patient,  if  a  child, 
should  be  placed  in  a  recumbent  position,  and  will 
probably  need  to  be  held  firmly  while  the  drops  are 
being  instilled  and  the  ointment  inserted.  Neither 
application,  it  may  be  observed,  causes  any  pain. 

As  to  constitutional  treatment,  this,  of  course,  will 
be  influenced  largely  by  the  age  and  the  general  con- 
dition of  the  patient.  When  there  are  present  evidences 
— enlarged  lymphatic  glands,  etc. — of  a  well-marked 
strumous  diathesis,  the  syrup  of  the  iodid  of  iron,  and 
cod-liver  oil  combined  with  the  hypophosphites  are 
especially  useful.  In  the  cases  which  are  less  distinctly 
strumous,  especially  in  those  which  have  been  described 
as  being  encountered  so  often  in  children,  the  remedy 
in  which  experience  has  led  me  to  place  the  greatest 
confidence  is  a  combination  of  the  phosphates  of  iron, 
quinin,  and  strychnin,  given  in  the  form  of  an  elixir  or 
a  syrup. "^  The  preparations  of  "beef,  wine,  and  iron," 
which  have  the  advantage  of  being  palatable,  a  matter 
of  no  little  importance  where  children  are  concerned,  I 
have  also  found  useful. 

*  As  has  been  mentioned  before,  the  eh'xir  of  the  phosphates  of 
iron,  quinin,  and  strychnin  made  byWyeth  &  Brother  is  especially  to 
be  commended,  because  it  contains  a  much  larger  proportion  of  iron 
and  quinin  (two  grains  of  the  former  and  one  grain  of  the  latter  to  the 
dram)  than  do  most  of  the  preparations  that  are  called  by  the  same 
name.  A  syrup  prepared  by  Sharp  &  Dohme,  which  contains  one 
grain,  each,  of  the  phosphates  of  iron  and  of  quinin  and  one-sixtieth 
of  a  grain  of  phosphate  of  strychnin  to  the  dram,  is  another  prepa- 
ration which  I  have  used  with  excellent  effect,  especially  in  hospital 
practice. 


192  PREVALENT    DISEASES    OF    THE    EYE. 

As  a  rule,  it  is  well,  especially  in  those  cases,  common 
in  children,  which  exhibit  besides  the  ocular  inflamma- 
tion other  signs  of  constitutional  disorder,  such  as 
blepharitis,  eczema,  nasal  catarrh,  otitis  media,  etc.,  to 
administer,  at  the  outset  of  the  treatment,  an  energetic 
mercurial  purgative  (calomel,  scammony,  aa  gr.  ij; 
rhubarb,  gr.  vj).  The  benefit  resulting  from  this 
measure  usually  is  strikingly  manifest,  and  not  infre- 
quently the  case  is  well  on  the  road  to  recovery  before 
the  tonic  treatment,  to  which  it  is  the  prelude,  has  had 
time  to  produce  its  effect. 

The  regulation  of  the  diet,  it  should  be  added,  espe- 
cially in  cases  occurring  in  children,  who  should  be 
allowed  to  have  only  simple,  easily  digested,  and  nourish- 
ing food,  is  a  matter  of  prime  importance.  It  is  impor- 
tant also  that  patients  suffering  with  phlyctenular  con- 
junctivitis or  kerato-conjunctivitis  should  be  out  of 
doors  as  much  as  practicable — should  have  plenty  of 
fresh  air  and  sunlight,  and  should  not  be  shut  up  in 
darkened  and  ill-ventilated  rooms,  as  too  often  happens. 

The  exanthematous  fevers,  measles  especially,  not 
infrequently  give  rise  to  inflammation  of  the  conjunc- 
tiva, and  writers  often  make  of  these  cases  a  distinct 
variety  of  conjunctivitis,  which  they  denominate  "ex- 
anthematous." There  seems  to  be  no  good  reason  for 
doing  so,  however,  as  they  differ  in  no  essential  respect 
from  the  systemic  conjunctivitis  that  has  just  been 
described,  and,  like  it,  present  at  times  a  distinctly 
phlyctenular  character,  with  a  tendency  to  corneal 
implication,  and,  at  other  times,  a  catarrhal  type; 
moreover,  the  treatment  which  they  require  is  exactly 
the  same. 

Toxic  Conjunctivitis. — An  inflammation  of  the 
conjunctiva  of  follicular  type,  usually  accompanied  by 


DISEASES    OF    THE    CONJUNCTIVA.  I93 

annoying  itching,  is  occasionally  excited  by  the  long- 
continued  use  of  collyria  containing  atropin,  hyoscy- 
amin,  eserin,  and  other  drugs  of  similar  character. 
Exceptionally,  owing  to  a  peculiar  susceptibility  on 
the  part  of  the  individual,  a  single  application  of  an 
atropin  collyrium  v^ill  induce  a  marked  conjunctivitis, 
which  may  be  accompanied  by  decided  redness  and 
edema  of  the  eyelids  and  even  of  the  whole  face.  Some- 
times this  susceptibility  is  manifested  to  all  of  the  com- 
monly employed  mydriatics,  but  usually  this  is  not  the 
case. 

Treatmetrf. — This  consists  in  withholding  the  drug 
to  which  the  susceptibility  is  shown,  and  in  the  use 
of  a  ten-grain-to-the-ounce  solution  of  boracic  acid, 
three  or  four  times  daily.  This  soon  restores  the  eye 
to  its  normal  condition. 

Argyria  Conjunctivae. — From  the  long-continued 
application  of  silver  nitrate  to  the  eye  a  permanent 
stain  of  the  lower  tarsal  and  retrotarsal  conjunctiva, 
and  not  infrequently  of  the  bulbar  conjunctiva  as  well, 
may  result.  The  "white  of  the  eye"  assumes  an  olive 
tint,  while  the  retrotarsal  folds  and  the  inner  surface 
of  the  lids  are  stained  a  bluish-gray  or  slate  color.  A 
similar  discoloration  of  the  conjunctiva  is  said  to  occur 
in  persons  who,  owing  to  the  nature  of  their  employ- 
ment, are  constantly  exposed  to  the  action  of  silver 
dust.  Cases  of  argyria  from  protargol  have  been  re- 
ported, and  as  this  agent  is  more  penetrating  in  its 
action,  and  can  be  used  more  freely  than  the  silver 
nitrate,  it  is  probable  that  this  condition  will  be  met 
with  oftener  in  the  future  than  it  has  been  in  the  past. 
The  stains  are  indelible.  Different  agents  have  been 
employed  to  remove  them,  but  without  success. 

Subconjunctival  Hemorrhage. — This  condition 
13 


194 


PREVALENT    DISEASES    OF    THE     EYE. 


(Fig.  82),  which  usually  manifests  itself  suddenly,  may 
occur  spontaneously  or  may  be  of  traumatic  origin. 
Spells  of  coughing,  vomiting,  or  sneezing  may  produce  it, 
while  at  other  times  it  occurs,  it  may  be  during  sleep, 
without  assignable  cause.  The  existence  of  angio- 
sclerosis  predisposes  to  it,  as  it  does  to  hemorrhages 
in  other  parts.  The  blood  not  infrequently  encircles 
the  cornea,  and  spreads  over  the  whole  anterior  surface 

of  the  eyeball,  giving  to  it 
a  bright-red  appearance, 
which  leads  to  the  belief 
that  something  serious  has 
happened.  It  is  commonly 
mistaken  for  "inflamma- 
tion"; but  inspection  of  the 
eye  shows  that  the  redness 
is  not  due  to  injection  of 
blood-vessels.  It  may  give 
rise  to  a  slight  soreness  of 
the  eyeball ;  but  beyond  this 
it  causes  no  inconvenience, 
apart  from  its  unsightliness. 
During  the  process  of  ab- 
sorption, which  may  occupy 
two  or  three  weeks,  the 
bright-red  color  of  the  freshly  extravasated  blood 
changes  to  a  greenish-yellow. 

Treatment  is  scarcely  called  for;  but,  if  it  is  a  matter 
of  moment  to  hasten  the  restoration  of  the  normal 
appearance  of  the  eye,  a  compress  bandage  and  the 
internal  administration  of  potassium  iodid  may  be  of 
some  avail.  A  lotion  of  opium  and  boracic  acid  is 
useful,  when  "soreness"  of  the  eyeball  is  complained  of. 
Pinguecula. — An  elevation,  yellowish  in  color,  and 


Fig.  82. — Subconjunctival  liemor 
rhage  (Haab). 


DISEASES    OF    THE    CONJUNCTIVA.  I9C 

varying  in  size  and  shape,  situated  upon  the  conjunc- 
tiva in  the  interpalpebral  space,  usually  in  close  prox- 
imity to  the  nasal,  and  less  frequently  to  the  temporal, 
margin  of  the  cornea,  was  given  the  name  pinguecula 
(from  pinguis,  "fat"),  because  formerly  it  was  sup- 
posed to  be  due  to  the  deposition  of  fat  in  the  con- 
junctiva. It  is  seldom  observed  in  young  persons, 
and  is  oftenest  met  with  in  individuals  who  have 
passed  middle  life.  The  fact  that  it  occurs  upon 
the  most  exposed  portion  of  the  bulbar  conjunctiva 
seems  to  indicate  that  it  is,  in  some  measure  at  least, 
due  to  the  irritation  caused  by  wind,  dust,  etc.  Micro- 
scopic investigation  has  shown  that  the  thickening  of 
the  conjunctiva  is  caused  mainly  by  an  increase  in  the 
number  and  size  of  its  elastic  fibers,  and  that  the  yellow 
color  is  due  not  to  the  deposition  of  fat,  but  to  the 
presence  of  numerous  concretions  of  a  yellowish  col- 
loid substance  (Fuchs). 

Treatment. — Removal  of  the  growth  is  sometimes 
indicated  on  account  of  its  unsightliness,  and  in  other 
instances  because,  when  unusually  prominent,  it  may 
cause  mechanical  irritation.  It  may  be  excised  with 
slender  curved  scissors,  care  being  taken  to  sacrifice 
as  little  as  possible  of  the  neighboring  conjunctiva. 
The  edges  of  the  conjunctival  wound  should  be  slightly 
undermined,  and  brought  together  by  one  or  two  fine, 
black  silk  sutures,  which  should  be  removed  after  two 
or  three  days. 

Pterygium  is  a  circumscribed  hypertrophy  of  the 
conjunctiva  and  subconjunctival  tissue,  of  triangular 
shape,  and  more  or  less  markedly  vascular,  which  ex- 
hibits a  tendency  to  encroach  upon  the  cornea.  The 
apex  of  the  growth  is  always  turned  toward  the  center 
of  the  cornea;  the  base  toward  the  equator  of  the  eye- 


igb  PREVALENT    DISEASES    OF     JHh     hVE. 

ball  (Plate  IV,  Fig.  2).  Its  usual  location  is  to  the 
nasal  side  of  the  cornea,  over  the  region  of  attachment 
of  the  tendon  of  the  internal  rectus  muscle;  exception- 
ally it  is  situated  upon  the  outer  side  of  the  cornea.  It 
develops  very  slowly,  and  months,  or  even  years,  may 
elapse  without  its  extending  far  enough  upon  the  cornea 
to  impair  vision.  It  is  rarely  met  with  in  children, 
and  it  is  more  prevalent  in  tropical  than  in  temperate 
countries. 

The  apex  of  a  pterygium  occasionally  reaches,  but 
very  rarely  passes  beyond,  the  center  of  the  cornea. 
I  have,  however,  met  with  one  case  in  which  a  pterv- 
gium  of  unusually  large  size,  starting  from  the  nasal 
side  of  the  eye,  grew  entirely  across  the  cornea  to  its 
external  margin.  The  other  eye  of  the  same  individual 
(a  woman  advanced  in  years)  also  exhibited  a  large 
pterygium,  which  already  had  passed  beyond  the  center 
of  the  cornea.  As  long  as  the  growth  is  confined  to 
the  conjunctiva  and  the  periphery  of  the  cornea  it 
causes  little  or  no  inconvenience,  apart  from  its  un- 
sightliness.  When,  however,  it  encroaches  upon  the 
pupillary  area  of  the  cornea  it  seriously  impairs  vision, 
not  only  by  obstructing  the  passage  of  light  into  the 
eye,  but  because  the  curvature  of  the  corneal  surface 
about  its  apex  is  so  altered  as  to  produce  a  high  grade 
of  irregular  astigmatism. 

The  question  of  the  etiology  of  pterygium  has  been 
much  discussed,  and  several  theories  have  been  ad- 
vanced to  account  for  its  occurrence  and  for  its  growth. 
In  order  to  a  clear  comprehension  of  the  matter,  it  is 
essential  that  a  sharp  distinction  should  be  drawn  be- 
tween true  pterygium^  which  so  far  we  have  been  con- 
sidering, and  pseudo-pterygium^  since  much  of  the 
confusion  regarding  the  etiology  of  this  affection  has 
arisen  from  failure  to  do  this. 


DISEASES    OF    THE    CONJUNCTIVA.  IQ7 

Pseudo-pterygium,  which  is  as  apt  to  develop  at  the 
upper  or  lower  margin  of  the  cornea  as  in  any  other 
direction  (whereas  true  pterygium  may  be  said  never 
to  occur  in  either  of  these  positions),  has  its  starting- 
point  in  the  presence  of  an  ulcer  or  wound  of  the 
cornea  near  its  margin,  to  which  a  knuckle  of  the 
swollen  and  overhanging  conjunctiva  becomes  adher- 
ent. Occasionally,  in  this  variety  of  pterygium, 
which  is  a  not  very  uncommon  consequence  of  gonor- 
rheal conjunctivitis,  and,  as  just  indicated,  of  marginal 
wounds  of  the  cornea,  only  the  apex  of  the  growth  is 
adherent  to  the  cornea,  and  it  is  possible  to  pass  a 
probe  under  the  body  of  the  pterygium.  It  is  mani- 
fest, therefore,  that  both  clinically  and  etiologically  this 
affection  differs  radically  from  true  pterygium. 

It  has  long  been  taught  that  the  development  of  true 
pterygium,  like  that  of  pinguecula,  is  favored  by 
conditions  which  bring  about  persistent  hyperemia  of 
the  conjunctiva,  as,  for  example,  exposure  of  the  eyes 
to  the  rays  of  a  tropical  sun,  as  in  long  sea  voyages,  or 
to  the  heat  from  furnaces  or  to  the  irritant  action  of 
dust  and  vapors,  as  in  mills  and  other  manufacturing 
establishments;  and  the  evidence  in  favor  of  this  view 
is  much  too  strong  to  be  put  aside.  Fuchs,  indeed, 
holds  that  a  pterygium  is  simply  a  pinguecula  which 
has  extended  onto  the  cornea,  and  in  doing  so  has 
drawn  the  conjunctiva  after  it.  While  it  is  undoubt- 
edly true  that  pterygium  not  infrequently  does  originate 
in  this  manner,  the  view  that  it  always  does  so  is  not, 
I  believe,  supported  by  clinical  observation.  Transi- 
tional types,  which  one  observer  might  call  pterygium, 
and  another  pinguecula,  are  often  encountered. 

Any  theory  which  would  satisfactorily  explain  the 
origin  of  pterygium  must,  it  seems  to  me,  account  for 


198  PREVALENT    DISEASES    OF    THE     EYE. 

the  fact  that  in  a  large  majority  of  instances  the  growth 
develops  to  the  nasal  side  of  the  cornea,  over  the  region 
of  the  internal  rectus  muscle.  This  the  theory  which 
I  advanced  some  years  ago — that  insufficiency  of  the 
internal  recti  muscles  (exophoria),  by  inducing  hyper- 
emia of  the  overlying  conjunctiva,  is  an  important 
factor  in  the  causation  of  pterygium — does  in  an  emi- 
nently satisfactory  manner.*  In  the  years  that  have 
elapsed  since  this  view  was  advanced,  the  frequency 
with  which  I  have  found  these  two  conditions — ptery- 
gium and  exophoria — associated,  has  convinced  me 
that  it  is  not  without  substantial  foundation. 

Treatment. — In  the  treatment  of  pterygium  little  is 
to  be  expected  except  from  operative  interference. 
However,  in  its  incipient  stage  its  growth  may  be  re- 
tarded, or  possibly  arrested,  by  the  correction  of  any 
muscular  anomaly  or  error  of  refraction  which  may  be 
present;  and  it  may  be  added  that  after  operation 
the  tendency  to  recurrence  may  be  controlled  in  the 
same  way.  In  this  connection  it  should  be  observed 
that  the  discomfort  (asthenopia)  of  which  persons  with 
pterygium  often  complain,  is  much  more  apt  to  be  due 
to  the  existence  of  a  muscular  or  refractive  error  than 
to  the  mere  presence  of  the  growth. 

The  propriety  of  resorting  to  operation  depends  upon 
several  considerations.  When  the  growth,  though  con- 
fined to  the  conjunctiva,  is  narrow  and  well-defined, 
it  is  advisable  to  operate;  but  if  it  is  broad  and  ill- 
defined,  it  is  well  not  to  interfere,  unless  it  is  known 
to  be  progressing,  because,  under  such  circumstances, 
there  is  no  assurance  that  the   condition  and  appear- 

*  See  "Trans.  Am.  Ophthalmolog.  Soc,"  Vol.  IV,  p.  537;  "Am. 
Journal  Ophthalmology,"  Aug.,  1887;  and  "Reference  Handbook 
of  the  Medical  Sciences,"  Vol.  VI,  p.  58. 


DISEASES    OF    THE    CONJUNCTIVA.  I99 

ance  of  the  eve  will  be  better  after  operation  than  it 
was  before.  When,  already,  the  growth  has  encroached 
upon  the  cornea,  it  is  best  not  to  postpone  operation, 
for  when  this  has  happened  it  usually  continues  to 
advance,  and  as  it  does  so  produces  changes  in  the 
corneal  structure  of  such  character  as  to  leave  a  more 
or  less  pronounced  permanent  opacity,  even  when  it 
has  been  removed  with  the  greatest  care. 

Of  the  many  operative  procedures  which  have  been 
proposed  for  the  cure  of  pterygium,  the  operation  of 
excision  is  the  only  one  which  I  am  disposed  to  com- 
mend. The  end  which  all  of  these  procedures  seek  to 
accomplish  is  the  same — to  minimize  the  loss  of  con- 
junctival tissue — and  this,  indeed,  is  of  the  first  impor- 
tance; but  when  excision  is  properly  performed  there 
need  be  but  little  sacrifice  of  tissue.  The  important 
point  to  bear  in  mind  is  that  while  the  corneal  portion 
of  the  growth  should  be  carefully  dissected  up  and  com- 
pletely removed,  the  conjunctival  portion  should  be 
dealt  with  much  less  radically,  should,  indeed,  be  only 
in  part  removed.  If  this  precaution  is  not  observed,  a 
large  gap  will  be  made  in  the  conjunctiva,  and  after  the 
completion  of  the  healing  process,  which  under  such 
circumstances  is  apt  to  be  slow  and  difficult,  a  con- 
spicuous, vascular  cicatrix  will  be  left,  which  may 
interfere  with  the  free  movements  of  the  eyeball,  and 
which  is  as  unsightly  as  was  the  pterygium  itself. 

The  method  of  operating  which  I  have  employed 
for  years,  and  which,  as  a  rule,  has  yielded  very  satis- 
factory results,  recurrence  of  the  growth  being  decidedly 
exceptional,  is  as  follows:  With  a  pair  of  slender, 
toothed  forceps  (such  as  are  used  in  operating  for 
squint)  the  pterygium  is  seized  near  its  apex,  and, 
while  considerable  traction  is  made  upon  it,  is  carefully 


200  PREVALENT    DISEASES    OF    THE    EYE. 

dissected  from  the  cornea  with  a  sharp  and  but  slightly 
bent  iridectomy  knife,  especial  care  being  taken  to 
detach  its  margins  from  the  corneal  limbus;  its  more 
loose  attachments  to  the  sclera  are  also  divided  for 
a  distance  of  3  or  4  mm.  from  the  border  of  the  cornea. 
Then  with  a  pair  of  slender  scissors,  curved  on  the 
flat,  the  whole  of  the  corneal  and  a  small  part  of  the 
conjunctival  portion  of  the  growth  is  excised  by  two 
converging  cuts.  During  this  step  of  the  operation 
but  slight  traction  is  exerted  with  the  forceps;  for,  if 
the  traction  is  considerable,  and  if  at  the  same  time 
the  scissors  are  pressed  against  the  sclera,  a  much 
larger  part  of  the  pterygium  will  be  removed  than  is 


a  b 

Fig.  83. —  Operation  for  the  removal  of  pter^-gium.  The  dotted 
lines  {a)  represent  the  portion  of  the  growth  which  is  excised;  b  represents 
the  conjunctival  wound  closed  by  two  stitches. 

desirable.  The  margins  of  the  conjunctival  wound 
are  now  slightly  undermined  with  the  scissors,  so  that 
they  may  be  more  readily  brought  together  by  two  su- 
tures of  fine  black  silk,  which  are  next  introduced  (Fig. 
83).  A  light  bandage  is  then  applied,  to  be  worn  until 
the  stitches  are  removed  on  the  second  or  third  day, 
when  a  collyrium  of  boracic  acid  (ten  to  twelve  grains 
to  the  ounce)  is  prescribed,  to  be  used  until  the  inflam- 
mation consequent  upon  the  operation  has  subsided. 
A  speculum  should,  of  course,  be  used  during  the 
operation,  and  the  eye  should  be  thoroughly  under  the 


DISEASES    OF    THE    CONJUNCTIVA.  201 

influence  of  cocain.  The  instillation  of  a  few  drops  of 
a  1 :  1000  adrenalin  solution  is  also  of  advantage,  as 
it  renders  the  operation  nearly,  if  not  quite,  bloodless. 

It  is  well  to  inform  the  patient  that  the  improvement 
in  the  appearance  of  the  eye  will  be  slow,  else  he  may 
suppose  the  operation  has  not  been  successful,  and 
may  mistake  the  localized  vascularity,  which  remains 
for  some  time,  for  a  return  of  the  growth. 


CHAPTER  Yl. 

DISEASES  OF  THE  CORNEA  AND  SCLERA. 

Diseases  of  the  Cornea, 
keratitis. 

Inflammation  of  the  cornea,  keratitis,  occurs 
as  a  primary  and  as  a  secondary  condition.  As  a 
secondary  condition  it  is  oftenest  observed  in  associa- 
tion with  the  severer  forms  of  conjunctivitis.  It  may 
be  acute  or  chronic  in  type,  may  involve  one  or  both 
eyes,  may  be  wholly  dependent  upon  local  causes  or 
may  be  constitutional  in  its  origin,  and  it  is,  not  infre- 
quently, a  result  of  traumatism.  It  is  commonly 
accompanied  by  pericorneal  subconjunctival  and  con- 
junctival injection,  a  contracted  pupil,  and  by  more  or 
less  marked  impairment  of  the  transparency  of  the 
cornea  and  loss  ot  its  surface  luster.  In  some  forms 
of  keratitis  the  development  of  blood-vessels  upon  or 
in  the  cornea  is  a  striking  feature.  It  is  usually  at- 
tended by  pain,  often  very  severe,  and  bv  photophobia 
and  lacrimation.  There  may  be  also  marked  impair- 
ment of  vision  if  the  corneal  opacity  is  dense  and  over- 
lies the  pupil. 

The  several  varieties  of  keratitis  may  be  grouped 
conveniently  under  two  heads — suppurative  keratitis 
and  nonsuppurative  keratitis.  To  the  former  group, 
characterized  by  a  tendency  to  tissue  necrosis,  belong 
phlyctenular  keratitis,  abscess  and  ulcer  of  the  cornea, 
keratomalacia,  and,  as  a  rule,  neuropathic  keratitis; 
to  the  latter,   interstitial  keratitis,  panniis  or  pannitic 


DISEASES    OF    THE    CORNEA    AND    SCLERA. 


203 


keratitis,  and  certain  comparatively  rare  forms  of 
corneal  inflammation — sclerosing  keratitis  and  kera- 
titis profunda — which  need  not  engage  our  attention, 
the  chiet  characteristic  of  this  group  being  chronicity. 

The  dangers  to  be  feared  in  keratitis  are  extensive 
necrosis  ot  the  corneal  tissue,  circumscribed  necrosis, 
as  in  perforating  ulcer,  the  formation  of  permanent 
opacities,  which  may  seriously  impair  sight,  and  altera- 
tions in  the  shape  of  the  cornea,  which  are  scarcely  less 
detrimental  to  vision  (Fig.  84).     The  control  of  the  in- 


Fig.  84. — Keratectasia  resulting  from  an  ulcer.  Magnified  25  X  i 
(Fuchs).  The  thinned  and  protruding  cicatrix  is  distinguished  by  its 
denser  texture  from  the  adjacent  normal  cornea.  The  epithelium,  e, 
over  it  is  thickened,  while  Bowman's  membrane,  b,  is  wanting.  On  the 
other  hand,  Descemet's  membrane,  d,  with  its  endothelium,  is  everywhere 
present- —  a  proof  that  the  ulcer  has  not  perforated. 

flammatory  process  as  quickly  as  possible,  so  that  the 
serious  consequences  just  enumerated  may  not  occur, 
and  the  relief  of  the  attendant  pain  and  photophobia, 
are  the  ends  to  which  treatment  should  be  directed. 

The  corneal  epithelium  (Fig.  85)  when  destroyed  by 
accident  or  disease,  it  mav  be  remarked,  is  quickly  re- 
generated; but,  on  the  other  hand,  Bowman's  membrane 
is  never  regenerated,  and  the  true  corneal  tissue  (the 
substantia  propria  of  the  cornea)  when  lost  is  replaced 
by  connective  tissue,  which  seldom  attains  the  transpar- 


204 


PREVALENT    DISEASES    OF    THE     EYE. 


ency  of  the  normal  cornea,  though  it  is  the  fixed  cor- 
neal cells  which  are  mainly  instrumental  in  its  forma- 
tion (Fig.  86). 

SUPPURATFVE  KERATITIS. 

In   the   production   of  the    different   forms   of  sup- 
purative   keratitis    bacteria    play    an    important    role. 


^*i^'»i»'.»jTii.»i^i^  u>uiL*i^,i^rjgi^i^i^i^f> 


Fig.  85. — Section  of  cornea  (Piersol):  a,  Anterior  epithelium;  c, 
anterior  limiting  (Bowman's)  membrane;  b,  b,  fibrous  stroma  of  substantia 
propria,  containing  corneal  corpuscles  (/)  lying  within  the  corneal  spaces; 
d,  posterior  imiting  (Descemet's)  membrane;  e,  endothelium  lining  an- 
terior chamber. 

Those  oftenest  concerned  are  the  Staphylococcus 
aureus,  the  streptococcus  and  the  pneumococcus.  The 
infection  usually  is  ectogenous,  though  in  many  in- 
stances undoubtedly  it  is  entogenous.  The  tractability 
or  intractability  of  this  type  of  keratitis  depends  upon 


DISEASES    OF    THE    CORNEA    AND    SCLERA. 


205 


the  micro-organism  concerned  in  its  production — the 
pneumococcus,  for  example,  giving  rise  usually  to  a 
severe  form  of  keratitis — and  the  bactericidal  energy  of 
the  cells  and  the  body  juices  which  the  invading  bac- 
teria must  encounter.  The  worst  cases,  unquestion- 
ably, are  those  in  which  the  more  virulent  bacteria  play 
a  part,  and,  from  one  cause  or  another,  meet  with 
exceptionally  feeble  resistance. 
Phlyctenular  Keratitis  or  Kerato-conjunctivi- 


Fig.  86. — Cicatrix  of  the  cornea  (Saemisch).  The  epithelium,  e, 
is  everywhere  present,  but  over  the  cicatrix  it  is  irregular,  and  in  places 
(at  a)  is  thickened.  Bowman's  membrane,  b,  is  wanting  at  the  site  of  the 
cicatrix.  The  latter  itself  is  distinguished  from  the  tissue  of  the  normal 
cornea  by  its  denser  and  less  regular  texture. 


tis. — In  treating  of  phlyctenular  conjunctivitis  it  was 
stated  that,  as  often  as  not,  the  cornea  is  involved  as 
well  as  the  conjunctiva  in  this  type  of  ophthalmia  (Fig. 
87).  It  was  stated  also  that  when  this  is  the  case  the 
photophobia  and  lacrimation  are  commonly  more  pro- 
nounced, and,  further,  that  it  is  through  this  involve- 
ment of  the  cornea  that  the  sight  is  at  times  perma- 
nently impaired,  the  impairment  of  sight  being  caused 
either  by  the  formation  of  a  persistent  corneal  opacity 
or,  in  the  case  of  an  ulcer  perforating  into  the  anterior 


206 


PREVALENT    DISEASES    OF    THE     EYE. 


chamber,  by  the  development  of  an  anterior  synechia 
and  the  consequent  displacement  or  obliteration  of  the 
pupil  (Fig.  lOo). 

As  to  treatment,  it  was  pointed  out  that  when  the 
involvement  of  the  cornea  is  attended,  as  it  often  is, 
by  pronounced  photophobia  and  lacrimation,  a  con- 
siderably stronger  solution  of  atropin  (gr.  ij-iv  to  -^j) 
than  is  commonly  used  when  the  inflammation  is  con- 
fined to  the  conjunctiva  should  be  employed. 

Since  the  two  conditions,  phlyctenular  conjunctivitis 


^.^S'^s.-^ 


Fig.  87. — Section  of  corneal  phlyctenule:  b,  Bowman's  membrane;  c, 
corneal  substance;  d,  Descemet's  membrane;  e,  epithelium;  /,  phlyctenule, 
consisting  of  a  deposit  of  round-cells  in  the  epithelial  layer  and  along  the 
course  of  the  nerve;  n,  twig  of  nerve  ending  in  epithelium  (modified  from 
Iwanoff). 


and  phlyctenular  keratitis,  are  essentially  the  same 
not  only  in  their  etiology  but,  except  in  the  particulars 
just  pointed  out,  in  their  clinical  history  and  their  treat- 
ment as  well,  there  remains  but  little  to  be  added  re- 
garding the  latter  condition,  except  to  say  that  when 
a  threatening  ulcer  has  taken  the  place  of  the  super- 
ficial ulcer  usually  left  by  the  breaking  down  of  a 
phlyctenule,  the  therapeutic  measures  recommended 
in  corneal  ulcers  having  a  different  origin — the  liberal 
administration  of  quinin  being  one  of  the  most  impor- 
tant— are  indicated. 


DISEASES    OF    THE    CORNEA    AND    SCLERA. 


207 


Abscess  and  Ulcer  of  the  Cornea. — In  nonsuppur- 
ative keratitis  the  inflammatory  infiltrate,  which  charac- 
terizes all  types  of  corneal  inflammation  (Fig.  88),  dis- 
appears more  or  less  completely  without  the  formation 
of  pus  and  without  necrosis  of  the  corneal  stroma. 
In  suppurative  keratitis,  on  the  other  hand,  the  infiltrate 
breaks  down,  pus  is  formed,  and  to  a  greater  or  less 
extent  necrosis  of  the  corneal  tissue  occurs.  When 
this  pus  formation  and  this  tissue  necrosis  take  place 
in  the  superficial  layers  of  the  cornea,  we  have  a  corneal 


Fig.  88. —  Infiltrate  in  the  cornea;  first  stage  of  keratitis  (Saemisch). 
The  epithelium,  e,  and  Bowman's  membrane,  b,  over  the  infiltrate  are 
preserved. 


ulcer;  when  they  occur  in  the  deeper  layers,  and  are 
shut  in,  in  front  and  behind,  by  tissue  which  is  rela- 
tively sound,  an  abscess  of  the  cornea. 

As  a  rule,  a  corneal  abscess  tends  to  become  con- 
verted into  an  ulcer  through  breaking  down  of  the 
overlying  corneal  substance.  Exceptionally,  the  under- 
lying tissue  breaks  down,  and  the  abscess  discharges 
into  the  anterior  chamber;  while  in  other  instances  the 
pus  burrows  extensively  between  the  corneal  layers, 
and  shows  little  disposition  to  make  toward  either  the 
anterior  or  the  posterior  surface  of  the  cornea. 


208  PREVALENT    DISEASES    OF    THE     EYE. 

As  may  be  inferred  from  this  description,  abscess 
and  ulcer  of  the  cornea  are  ahke  in  their  etiology,  and 
differ  but  little  in  the  symptoms  which  attend  them. 
Among  their  commoner  causes  may  be  mentioned 
traumatism,  complicated  by  bacterial  infection;  puru- 
lent conjunctivitis;  blennorrhea  of  the  lacrimal  sac; 
abnormal  exposure  of  the  cornea,  such  as  may  result 
from  paralysis  of  the  orbicularis  muscle;  a  lowered 
state  of  the  general  system,  as  after  typhoid  fever  or 
the  exanthematous  fevers;  auto-infection,  from  the 
alimentary  canal  especially;  senility;  and  disturbances 
in  the  nerve-supply  of  the  cornea,  having  their  origin 
usually,  it  seems  probable,  in  the  gasserian  or  in  the 
ophthalmic  ganglion. 

A  moment's  reflection  will  show  that  the  mode  of 
action  of  these  various  causes  is  essentially  the  same; 
that  they  all— the  traumatism,  the  neuro-paralysis,  the 
lowered  vitality  of  the  system,  etc. — pave  the  way  for 
successful  bacterial  invasion  of  the  corneal  tissue. 

The  symptoms  common  to  the  two  conditions  are 
pain,  often  very  severe,  and  referred  not  only  to  the 
eye  but  to  the  brow,  temple,  and  side  of  the  head, 
photophobia,  lacrimation,  and  blepharospasm.  Ex- 
ceptionally, especially  in  the  aged,  an  ulcer  may  de- 
velop in  the  cornea  without  attendant  pain  or  photo- 
phobia. Inspection  of  the  eye  shows  circumscribed 
opacity  of  the  cornea,  marked  conjunctival  injection, 
more  pronounced  in  the  neighborhood  of  the  ulcer  or 
abscess,  a  contracted  pupil,  frequently  decided  edema 
of  the  lids,  slight  muco-purulent  discharge,  and  in  the 
more  unfavorable  cases  hypopyon — a  collection  of  pus 
or  of  fibrin  and  round  cells  in  the  lower  part  of  the 
anterior  chamber  (Plate  V,  Fig.  i).  In  the  case  of  an 
abscess,  the  opacity  will  be  beneath  the  surface  of  the 


PLATE  V. 


Fig.   I. — Corneal  Ulcer,  with  Hypopyon. 


S.lKcotaZlj 


Fig.  2. — Interstitial  Keratitis. 


DISEASES    OF    THE    CORNEA    AND    SCLERA. 


209 


cornea,  which  will  be  seen  to  be  intact.  If  an  ulcer  be 
present,  there  will  be  a  manifest  loss  of  substance,  an 
excavation,  which  may  be  shallow  or  deep,  and  vary 
greatly  in  extent. 

Much  may  be  learned  as  to  the  condition  of  a  corneal 
ulcer  by  careful  inspection,  especially  with  the  aid  of  ob- 
lique illumination.  If  it  be  in  a  progressive  stage,  its 
walls  will  be  opaque  and  its  edges  ragged  and  somewhat 
undermined  (Fig.  89);  if  in  a  regressive  stage,  if  the  re- 


Fig.  89. —  Corneal  ulcer  in  progressive  stage  (Saemisch).  The  base 
of  the  ulcer  is  formed  by  an  accumulation  of  pus  cells,  which  also  push 
their  way  some  distance  in  between  the  lamellae  of  the  cornea  that  adjoin 
the  ulcer.  At  the  edges  of  the  ulcer,  which  are  somewhat  raised,  the 
epithelium,  e,  and  Bowman's  membrane,  h,  end  as  if  cut  short  off. 


parative  process  has  been  established,  it  will  present  a 
cleaner  appearance,  its  walls  will  be  nearly  transparent, 
and  its  edges  rounded  off  (Fig.  90),  and,  especially  if 
it  be  near  the  corneal  border,  newly  formed,  superficial 
blood-vessels  will,  perhaps,  be  seen  running  to  its  margin 
from  the  neighboring  conjunctiva. 

There  is  a  vast  difference  in  the  behavior  and  in  the 

tractability  of  corneal  ulcers.     In  some  instances  they 

are  uncontrollable,  and  tend  to  go  from  bad  to  w^orse 

in  spite  of  all  that  can  be  done  to  combat  them;    in 

14 


210 


PREVALENT    DISEASES    OF    THE    EYE. 


Others,  they  show  a  disposition  to  do  well,  and  respond 
promptly  and  favorably  to  treatment.  It  is  usual  to 
denominate  ulcers  of  the  former  type  "infected"  ulcers, 
and  those  of  the  latter,  "simple"  ulcers;  but  this  nomen- 
clature is  open  to  objection,  for  even  the  mildest  ulcers 
are  "infected,"  in  the  sense  that  bacteria  nearly  always 
play  a  part  in  their  production. 

We  have  yet  much  to  learn  regarding  the  etiology  and 
pathology  of  corneal  ulcers;  but  enough  already  is  known 


Fig.  90. —  Corneal  ulcer  in  regressive  stage  (Saemisch).  The  base 
of  the  ulcer  is  formed  by  the  denuded  lamellae  of  the  cornea;  a  slight  in- 
crease in  the  number  of  cells  between  them  can  still  be  made  out.  .^t  the 
edges,  b,  of  the  ulcer  the  epithelium,  e,  is  beginning  to  grow  out  over  the 
base.  Newly  formed  blood-vessels  (g)  lying  in  the  upper  layers  of  the  cor- 
nea run  to  the  ulcer. 


to  warrant  the  Statement  that  their  malignancy  does  not 
depend  upon  the  mere  presence  of  bacteria,  but  rather 
upon  the  nature  of  the  bacteria  and,  scarcely  to  a  less 
degree,  upon  the  character  of  the  opposition — feeble  or 
energetic — which  they  encounter  in  their  invasion  of  the 
corneal  tissue;  When,  in  consequence  of  lowered  general 
vitality  or  of  unusual  local  conditions,  this  resistance  is 
exceptionally  inefficient,  even  the  less  virulent  bacteria, 
such  as  the  Staphylococcus  pyogenes  aureus,  may  do 
irreparable  damage;  but  usually  when  the  infection  is  of 


"      DISEASES    OF    THE    CORNEA    AND    SCLERA.  211 

this  character  the  ulcer  is  benign  and  not  difficult  to 
control.  On  the  other  hand,  when 'there  is  a  strepto- 
coccus infection,  or  when  the  pneumococcusor  the  Klebs- 
Loffler  bacillus  is  present,  the  ulcer  is  apt  to  exhibit 
greater  malignancy,  and  to  tax  our  therapeutic  powers. 

Systematic  writers  upon  diseases  of  the  eye  com- 
monly speak  not  only  of  "simple"  and  "infected" 
ulcers,  but  they  describe  several  kinds  of  "infected" 
ulcers,  to  which  they  give  particular  names,  such  as 
serpent  or  acute  sloughing  ulcer,  marginal  or  ring  ulcer, 
herpetic  or  dendritic  ulcer,  and  hypopyon  ulcer.  It 
would  serve  no  useful  purpose  to  describe  and  consider 
each  of  these  at  length;  but  it  may  be  stated  briefly 
that  the  serpent  ulcer,  which  shows  a  tendency  to 
progress  in  a  tortuous  course  upon  the  cornea,  is  often 
of  traumatic  origin,  is  usually  attended  by  hypopyon, 
and  is  especially  dangerous,  causing  loss  of  sight 
not  infrequently  through  involvement  of  the  deeper 
structures  of  the  eye;  that  the  ring  ulcer,  which  tends 
to  encircle  the  cornea  close  to  its  margin,  often  proves 
intractable,  and  in  the  worst  cases  may  lead  to  blindness 
through  complete  necrosis  of  the  cornea;  and  that  the 
dendritic  ulcer — named  because  of  its  fancied  resem- 
blance to  a  fern  leaf,  and  also  called  mycotic  ulcer, 
because  in  some  instances  it  has  been  found  to  be 
infected  with  a  fungous  growth — is  obstinate  in  charac- 
ter, owing  to  its  herpetic  origin  is  not  infrequently 
attended  by  anesthesia  of  the  cornea  and  by  marked 
ciliary  irritation,  is  met  with  at  times  as  a  sequel  of 
malarial  fever,  and  is  prone  to  leave  in  its  wake  a  much 
more  persistent  and  conspicuous  opacity  than  the  shght 
loss  of  substance  which  commonly  attends  it  would 
lead   one  to   expect. 

Treatment. — In  the  treatment  of  abscess  and  ulcer 


212  PREVALENT    DISEASES    OF    THE    EYE. 

of  the  cornea  constitutional  measures  are  scarcely  of 
less  importance  than  local  measures.  By  means  ot 
constitutional  measures  it  is  possible  to  strengthen  the 
combative  powers  of  the  cornea,  and,  when  the  infection 
is  entogenous,  to  rid  the  system,  in  large  measure 
perhaps,  of  the  bacteria  and  t-heir  toxins  which  are 
responsible  for  the  local  malady.  By  the  use  of  local 
applications  we  are  able  to  enfeeble  or  destroy  the 
bacteria  at  their  point  of  attack,  and  to  put  the  eye 
in  the  most  favorable  condition  to  resist  their  destruc- 
tive action. 

Quinin,  in  liberal  doses,  is  the  constitutional  remedy 
of  greatest  value,  since,  perhaps  bv  increasing  the  phago- 
cytic action  of  the  cells  or  the  bactericidal  energy  of  the 
body  iuices,  it  unquestionably  reinforces  the  resisting 
power  of  the  cornea.'*'  An  energetic  calomel  purge  is  the 
agent  which,  by  unloading  the  alimentary  canal,  ac- 
complishes most  toward  ridding  the  system  of  bacteria 
and  their  poisonous  products. 

The  most  useful  local  remedies  are  atropin,  holocain, 
dionin,  occasionally  eserin,  and,  as  bactericides,  boracic 
acid,  yellow  oxid  of  mercury,  chlorin  water,  carbolic  acid, 
curettage,  and,  under  exceptional  circumstances,  the 
actual  cautery.  The  opium  and  boracic  acid  lotion, 
which  has  been  mentioned  so  often,  is  a  valuable  ad- 
juvant. In  benign  ulcers,  such,  for  example,  as  occur 
in  phlyctenular  keratitis,  a  one-grain  solution  of  atropin, 
with  the  addition  of  boracic  acid  (gr.  x-xv  to  5j),  applied 
three  to  four  times  a  day,  and  supplemented  by  the  daily 
application  of  yellow  oxid  of  mercury  ointment  (gr.j 
to  vaselin  oj),  is  in  most  instances  efficacious.  Chlorin 
water,  which   should   be  of  full   strength   and   freshly 

*  Mercury,  given  so  as  to  impress  the  system,  produces  exactly 
the  opposite  effect. 


DISEASES    OF    THE    CORNEA    AND    SCLERA.  213 

prepared,  is  a  valuable  remedy  in  less  benign  ulcers, 
especially  those  of  traumatic  origin.  Its  application 
causes  little  or  no  discomfort,  and  it  should  be  dropped 
into  the  eye  freely  every  two  or  three  hours,  being  used 
in  conjunction  w^ith  atropin  or  holocain. 

The  existence  of  pain,  photophobia,  and  lacrimation 
is  an  indication  for  employing  a  strong  solution  of 
atropin  (gr.  iv  to  5j).  Holocain  (the  hydrochlorate)  is 
used  in  one-  to  two-grain  solution,  and  with  this  also 
it  is  well  to  combine  boracic  acid.  It  should  be  ap- 
plied once  in  three  hours.  It  may  be  used  instead  of 
atropin,  when  the  latter  does  not  act  favorably,  or  in 
conjunction  with  it.  It  relieves  pain,  and  promotes 
the  healing  of  the  ulcer,  partly,  at  least,  by  favoring 
the  formation  of  new  blood-vessels  upon  the  cornea. 
Although  an  anesthetic,  it  does  not,  like  cocain,  dilate 
the  pupil  or  disturb  the  corneal  epithelium.  Dionin, 
which,  in  conjunction  with  atropin  or  holocain,  may  be 
used  in  five  per  cent,  solution,  as  often  as  three  times  a 
day,  not  only  relieves  pain,  but  furthers  the  process  of 
repair  and  the  absorption  of  inflammatory  products 
through  its  stimulant  action  upon  the  lymph  currents 
of  the  eye.  The  lotion  of  opium  (ext.  opii,  gr.  x-xv; 
acid,  boracic,  gr.  xl-lx;  aquae  destil.,  oiv),  if  accept- 
able to  the  eye,  should  be  used  freely,  being  applied 
more  or  less  constantly  to  the  closed  lids  upon  a  gauze 
or  linen  pad.  Eserin  is  indicated,  in  my  judgment,  only 
when  there  is  increased  intraocular  tension,  and,  because 
of  its  tendency  to  produce  iritis,  it  should  be  used  with 
caution  and  only  in  weak  solution  (gr.  ^-j  to  5j). 

In  ulcers  that  are  foul  and  show  a  disposition  to 
extend  carbolic  acid,  in  full  strength,  carefully  applied 
directly  to  the  ulcer,  and  usually  preceded  by  cautious 
curetting,  often  accomplishes  great  good,  changing  the 


214  PREVALENT    DISEASES    OF    THE     EYE. 

character  of  the  ulcer,  and  inducing  the  process  of 
repair.  To  facihtate  the  appHcation  the  eye  should 
be  thoroughly  cocainized,  which  renders  the  procedure 
painless.  The  application  may  be  made  conveniently 
by  means  of  a  finely  pointed  wooden  toothpick,  about 
the  tip  of  which  a  few  fibers  of  absorbent  cotton  have 
been  wound.  If  much  cotton  is  used,  an  excess  of  the 
acid  will  be  taken  up,  and  it  will  be  almost  impossible 
to  prevent  its  spreading  over  healthy  portions  of  the 
cornea.  The  acid  should  be  applied  to  the  ulcer  thor- 
oughly by  a  gentle  rubbing  movement,  which  is,  in 
effect,  a  sort  of  curettage.  If  the  ulcer  is  lined  by 
infected  and  necrotic  material,  this  should  be  removed 
with  a  small  curet  before  the  application  of  the  acid. 
When,  however,  this  condition  is  less  pronounced,  aided 
by  the  loosening  action  of  the  cocain,  the  cleaning  of 
the  ulcer  may  be  effected  satisfactorily  by  means  of  a 
toothpick,  armed  with  a  wisp  of  dry  absorbent  cotton. 
After  the  acid  has  been  allowed  to  remain  in  contact 
with  the  ulcer  for  a  few  moments,  the  lids  meantime 
being  held  apart,  its  further  action  should  be  arrested 
by  flushing  the  cornea  with  sterile  water,  normal  salt 
solution,  or  a  saturated  solution  of  boracic  acid.  Some 
smarting  may  be  felt  in  the  eye  after  the  effect  of  the 
cocain  has  passed  off,  but  usually  this  is  not  pronounced. 
The  application  may  be  repeated  after  twenty-four 
hours,  should  the  ulcer  still  present  a  foul  appearance. 
The  timely  employment  of  carbolic  acid  in  the  careful 
manner  just  described  will  reduce  to  a  minimum  the 
cases  in  which  resort  to  the  actual  cautery  will  be  de- 
manded. However,  when  the  condition  of  the  ulcer 
is  not  improved  by  the  application  of  the  acid,  or  when 
the  ulcer  is  extending  rapidly  and  perforation  of  the 
cornea  is  imminent,  the  actual  cautery  should  be  em- 


DISEASES    OF    THE    CORNEA    AND    SCLERA. 


215 


ployed.  The  galvanocautery,  provided  with  a  very 
dehcate  platinum  tip,  is  best  adapted  for  the  purpose. 
So  energetic  an  agent,  however,  should  be  employed 
only  by  those  skilled  in  its  use,  since  in  untrained  hands 
it  is  apt  to  do  irreparable  damage  to  the  delicate  struc- 
tures of  the  eye. 

Paracentesis  of  the  anterior  chamber  for  the  purpose 
of  removing  the  hypopyon,  which,  as  has  been  said,  is 
often  present  in  the  more  malignant  types  of  corneal 
ulcers,  and  incision  of  corneal  abscesses  with  a  view 
of  giving  vent  to  the  insignificant  amount  of  pus  which 
they  commonly  contain,  are  procedures  of  doubtful 
value,  which  were  formerly  more  in  vogue  than  they 
are  at  present.  The  traumatism  involved,  more  espe- 
cially in  the  first-mentioned  procedure,  seems  not  infre- 
quently to  turn  the  scales,  and  to  hasten  the  impending 
total  necrosis  of  the  cornea.  However,  an  abscess 
which  is  extending  laterally,  and  shows  no  disposition 
to  reach  the  surface,  should  be  opened  by  the  removal 
of  the  overlying  corneal  tissue  with  a  curet,  and  should 
then  be  treated  as  one  would  treat  a  malignant  ulcer — 
by  the  application  of  carbolic  acid  or  the  galvano- 
cautery. 

Keratomalacia. — As  the  name  indicates,  this  is  a 
softening  or  sloughing  of  the  cornea.  Though  not  one 
•  of  the  commoner  diseases  of  the  eye,  it  has  seemed  to 
me  to  demand,  at  least,  brief  consideration,  since  it  is 
a  malady  which  the  general  practitioner  may  be  called 
upon  at  any  time  to  recognize  and  treat.  It  is  a  con- 
dition rarely  met  with  except  in  children,  and  occurs 
in  them  as  a  result  usually  of  some  exhausting  disease, 
such  as  scarlet  fever,  measles,  typhus  fever,  or  inherited 
syphilis,  or  as  a  consequence  of  malnutrition  from 
insufficient  or  improper  food.     It  is  attended  by  none 


210  PREVALENT    DISEASES    OF    THE     EYE. 

of  the  usual  symptoms  of  corneal  inflammation,  such 
as  pain,  photophobia,  and  lacrimation;  indeed,  dimin- 
ished lacrimation  is  a  feature  of  the  disease.  It  is 
frequently  preceded  by  night-blindness,  which  is  simply 
another  manifestation  of  the  lowered  general  vitality, 
and  by  desiccation  of  the  corneal  and  conjunctival 
epithelium.  It  commonly  affects  both  eyes,  and  the 
necrotic  process,  which  is  clearly  the  result  of  unop- 
posed bacterial  invasion,  may  progress  so  rapidly  as  to 
cause  complete  destruction  of  the  corneae  within  a  few 
hours.  (See  Fig.  66.)  It  is  accompanied  by  pericor- 
neal, venous  injection  of  a  dusky  red  color. 

Fortunately,  the  children  attacked  by  this  terrible 
malady  seldom  long  survive  the  ocular  involvement, 
but  die  from  general  exhaustion  or  from  some  inter- 
current affection,  such  as  pneumonia  or  bronchitis. 

Treatment. — This  is  of  little  avail  after  the  corneal 
necrosis  has  commenced.  The  indications  are  to  im- 
prove the  general  condition  of  the  child  by  every  means 
possible — by  nourishing  diet,  stimulants,  and  tonics, 
quinin  especially,  and  to  apply  soothing  and  antiseptic 
remedies  to  the  eyes,  atropin,  in  weak  solution,  or  holo- 
cain,  and  chlorin  water  or  a  saturated  solution  of 
boracic  acid.  If  the  case  is  seen  before  the  cornea  has 
begun  to  break  down,  during  the  period  of  night- 
blindness  and  conjunctival  desiccation,  the  energetic 
employment  of  the  measures  indicated  may  prevent 
the  loss  of  sight. 

Neuropathic  Keratitis. — This  variety  of  keratitis, 
that  is  to  say,  keratitis  dependent  primarily  upon  disorder 
of  the  nerve-supply  of  the  cornea,  is,  in  my  opinion,  of 
much  more  frequent  occurrence  than  is  commonly  sup- 
posed. The  more  severe  types  of  this  affection,  such 
as  arise  from  serious  lesions  of  the  fifth  nerve  or  of  the 


DISEASES    OF    THE    CORNEA    AND    SCLERA.  21/ 

gasserian  ganglion,  it  is  true,  are  not  common;  but  the 
milder  forms,  characterized  by  more  or  less  pronounced 
anesthesia  of  the  cornea,  and  having  their  origin,  prob- 
ably, in  pathological  changes  in  the  ophthalmic  gang- 
lion, are  often  encountered.  Doubtless  in  some  cases  of 
corneal  inflammation  originating  in  this  manner 
bacteria  play  a  part, — an  important  part  in  those  which 
are  attended  by  suppuration  and  considerable  loss  of 
corneal  substance, —  but  the  prime  factor  in  the  pro- 
duction of  this  type  of  keratitis  is  the  disturbance  in  the 
metabolism  of  the  cornea  due  to  the  derangement  of 
its  nerve-supply.  Probably  the  sympathetic  fibers 
which  pass  from  the  ophthalmic  ganglion  to  the  eye 
have  most  to  do  with  this  disturbance;  but,  at  all 
events,  the  sensory  fibers,  as  well,  usually  are  involved, 
as  is  shown  by  the  corneal  anesthesia. 

Keratitis  from  Lesions  of  the  Ophthalmic  Division  of 
the  Fifth  Nerve,  its  Nucleus,  or  the  Gasserian  Ganglion. 
— In  serious  lesions  of  the  ophthalmic  division  of  the 
fifth  nerve  or  its  nucleus,  or  of  the  gasserian  ganglion, 
severe  and  rapidly  destructive  inflammation  of  the 
cornea  at  times  occurs.  Under  such  circumstances  we 
first  observe  a  lack  of  luster,  quickly  followed  by  des- 
quamation, of  the  corneal  epithelium.  Then  the  anes- 
thetic cornea,  which,  owing  to  the  lessened  activity  of 
the  lacrimal  gland,  is  not  bathed  and  moistened  by  the 
tears  as  it  is  under  normal  conditions,  becomes  cen- 
trally clouded  and  then,  perhaps,  rapidly  necrotic. 

The  view,  widely  held,  that  this  is  a  purely  traumatic 
inflammation,  due  to  injuries  received  in  consequence 
of  the  want  of  sensibility  of  the  cornea,  always  has 
seemed  to  me  chimerical.  A  more  reasonable  ex- 
planation, as  has  already  been  suggested,  is  that  owing 
to  its  deranged  metabolism  the  cornea  is  in  a  state  of 


2l8  PREVALENT    DISEASES    OF    THE     EYE. 

unstable  equilibrium,  so  to  speak, — a  state  in  which, 
with  all  other  conditions  favorable,  its  vitality  is  hardly 
maintained.  Under  such  circumstances,  with  the 
corneal  epithelium  denuded,  the  conditions  are  ideally 
favorable  for  destructive  bacterial  action;  so  that  even 
the  less  virulent  micro-organisms  that  are  not  infre- 
quently present  in  the  conjunctival  sac,  and  that 
usually  are  harmless,  are  now  able  to  overcome  the 
feeble  resistance  opposed  to  them,  and  to  cause  destruc- 
tion of  the  corneal  tissue. 

Herpes  Zoster  Ophthalmicus. — Another  severe  type 
of  neuropathic  keratitis,  which  fortunately,  like  that 
just  described,  is  not  common,  is  that  which  is  met 
with  in  herpes  zoster  ophthalmicus.  Here,  as  is  wtII 
known,  the  primary  lesion  is  in  the  gasserian  ganglion. 
Usually  in  this  affection  the  ocular  inflammation 
is  not  limited  to  the  cornea,  but  involves  the  iris  and 
at  times  the  deeper  portions  of  the  uveal  tract  as  well. 

The  keratitis  of  herpes  zoster,  w^hich  is  almost 
always  unilateral,  is  usually  obstinate,  deep-seated,  and 
attended  by  severe  pain  and  pronounced  photophobia. 
At  the  outset  vesicles,  commonly  in  groups,  make  their 
appearance  upon  the  cornea.  These  rupture  early, 
and  leave  superficial  ulcers,  which  may  extend  deeply 
into  the  corneal  tissue.  Anesthesia  of  the  cornea,  as 
well  as  of  the  lids  and  forehead,  is  present.  The  one- 
sided eruption  upon  the  upper  lid,  forehead,  and  scalp, 
and  less  frequently  upon  the  side  of  the  nose,  is  char- 
acteristic, and  indicates  the  true  nature  of  the  affec- 
tion (Fig.  91).  Perforation  of  the  cornea  rarely  occurs, 
but  indelible  opacities  are  frequently  left,  which 
may  seriously  and  permanently  impair  sight. 

The  milder  forms  of  neuropathic  keratitis,  under  which 
head   I    would    include    herpes    corneae    febrilis,  post- 


DISEASES    OF    THE    CORNEA    AND    SCLERA. 


219 


malarial  keratitis,  and  dendritic  keratitis,  are,  as  has 
been  said,  of  frequent  occurrence.  They  appear  to  arise 
from  a  variety  of  causes,  and  often  occur  without  assign- 
able reason.  They  are  characterized  by  more  or  less 
pronounced  anesthesia  of  the  cornea;  may  be  attended 
by  the  formation  of  vesicles,  by  superficial  ulceration  or 
simply  by  inflammatory  infiltration;  are  inclined  to  be 
intractable;  are  almost  invariably  monocular,  and  are 
apt  to  leave  persistent  opacities,  out  of  proportion  to  the 
loss  of  tissue  which  attends  them  (Fig.  92).       Among 


rig.  91. — Herpes  zoster  ophthalmicus 
(Posey  and  Wright). 


Fig.    92. — Herpetic    (neurooathic) 
keratitis  (Haab). 


their  known  causes  may  be  mentioned  "cold,"  malarial 
fever,  influenza,  bronchitis,  pneumonia,  typhoid  fever, 
reflex  dental  irritation,  and  probably  rheumatism, 
gout,  and  syphilis. 

I  have  long  believed,  though  I  have  no  definite  evi- 
dence to  off"er  in  support  of  this  belief,  that  the  primary 
lesion  in  these  types  of  keratitis  is  in  the  ophthalmic 
ganglion.  That,  in  fact,  we  have  here  a  condition 
closely  related  to  herpes  zoster  ophthalmicus,  the 
difference  being  that  in  one  case,  the  primary  lesion 


220  PREVALENT    DISEASES    OF    THE    EYE. 

being  in  the  gasserian  ganglion,  the  resultant  inflam- 
matory changes  and  the  attendant  anesthesia  manifest 
themselves  not  only  in  the  eye  but  in  other  regions — 
the  lid,  forehead,  etc. — supplied  by  the  fifth  nerve; 
while  in  the  other,  in  which  the  original  fault  is  in 
the  ophthalmic  ganglion,  the  consequent  inflammation 
and  anesthesia,  as  might  be  expected,  are  limited  to 
the  eye  itself.  A  significant  fact,  worthy  of  mention 
in  this  connection,  is  that  malarial  fever,  which  is  one 
of  the  most  definitely  proved  causes  of  the  type  of 
neuropathic  keratitis  we  are  considering,  is  also  a 
recognized  cause  of  herpes  zoster.  The  unilateral 
character  of  both  aff'ections  is  also  significant. 

Post-malarial  Keratitis. — One  of  the  most  typical 
examples  of  the  milder  variety  of  neuropathic  keratitis 
is  that  which  follows  malarial  fever.  In  this  affection, 
which  is  unilateral,  and  is  attended  by  marked  ciliary 
irritation, — pain,  photophobia,  and  lacrimation, — we 
have  impairment  of  corneal  sensibility  and  superficial 
inflammatory  infiltration  and  ulceration,  the  ulcer 
showing  but  little  tendency  to  spread,  and  often  exhibit- 
ing a  branched  or  arborescent  form.  Closely  related 
to  this,  frequently  not  to  be  distinguished  from  it,  and 
in  many  instances,  probably,  identical  with  it,  is  the 
so-called  dendritic  keratitis.  The  close  resemblance 
of  these  two  affections,  for  they  are  alike  not  only  in 
appearance  but  in  general  behavior,  is  to  be  attributed, 
I  believe,  to  the  probable  fact  that,  whatever  the 
inducing  cause,  each  has  its  origin  in  disease  of  the 
i  ophthalmic  ganglion.  The  characteristic  feature  of 
hej^es  cornea  febrilis,  another  nearly  related  affection, 
attended  by  impaired  sensibilitv  of  the  cornea  and 
almost  without  exception  unilateral,  is  the  appearance  at 
the  outset  of  the   attack   of  numerous   small  vesicles. 


DISEASES    OF    THE    CORNEA    AND    SCLERA.  221 

which  soon  rupture,  leaving  superficial  ulcers,  that  not 
infrequently  present  the  same  dendritic  or  arborescent 
form  just  spoken  of.* 

Treatment. — In  the  treatment  of  neuropathic  kera- 
titis, as  may  be  inferred  from  what  has  been  said  as  to 
its  etiology,  constitutional  as  well  as  local  remedies  are 
called  for.  The  most  useful  local  remedy,  indicated  in 
all  of  its  forms,  is  atropin,  with  which  it  is  well  to  com- 
bine boracic  acid.  Depending  upon  the  amount  of 
pain,  photophobia,  etc.,  present,  the  strength  of  the 
solution  prescribed  should  vary  from  one  to  four 
grains  to  the  ounce.  Holocain,  in  one-grain-to-the- 
ounce  solution,  is  also  useful,  and  so  is  the  lotion  of 
opium  and  boracic  acid.  When,  in  the  ulcerative 
forms,  secondary  bacterial  infection  is  found  to  have 
occurred,  chlorin  water,  employed  as  recommended 
in  other  intractable  corneal  ulcers,  is  valuable,  and 
under  such  circumstances  it  may  become  necessary  to 
resort  to  curettage  and  the  application  of  pure  carbolic 
acid. 

In  the  severe  type  of  neuropathic  keratitis  which 
results  from  lesion  of  the  fifth  nerve  or  its  nucleus  one 
of  the  most  important  measures  is  to  keep  the  lids 
constantly  closed  by  a  light  and  evenly  applied  ban- 
dage, so  as  to  afford  the  eye  as  complete  protection  as 
possible.  In  herpes  zoster  ophthalmicus  the  syste- 
matic use  of  atropin  in  strong  solution  (gr.  iv  to  oj) 
is  especially  indicated,  not  only  on  account  of  the 
severe  pain  which  commonly  attends  it,  but  because  of 
the  danger  that  iritis  may  develop  at  any  time. 

The  most  valuable  constitutional  remedy  is  quinin, 

*  Fuchs,  than  whom,  on  such  a  point,  there  is  scarceh'  a  higher 
authority,  seems  not  disposed  to  make  a  distinction  hetween  herpes 
corneae  febriHs  and  keratitis  dendritica. 


222  PREVALENT    DISEASES    OF    THE     EYE. 

which  should  be  given  with  sufficient  freedom — three 
grains,  four  or  five  times  a  day — to  produce  moderate 
cinchonism.  Its  usefulness  is  by  no  means  confined 
to  the  post-malarial  type  of  neuropathic  keratitis,  but 
is  manifested  in  all  varieties  of  the  affection.  Strych- 
nin, which  may  be  given  in  association  with  the  quinin, 
is  useful  also,  and  iron  should  be  prescribed  when  the 
condition  of  the  system  seems  to  call  for  it.  Arsenic, 
a  remedy  often  recommended,  I  have  found  rather 
disappointing  in  its  effect.  Next  to  quinin,  I  am  dis- 
posed to  regard  potassium  iodid  as  the  drug  most 
apt  to  accomplish  good.  In  prescribing  it  I  have  had 
in  view  its  effect  upon  the  hypothetical  lesion  ot  the 
ophthalmic  ganglion — for  it  is  especially  in  the  milder 
forms  of  neuropathic  keratitis  that  it  has  proved  effica- 
cious— rather  than  anv  direct  influence  which  it  might 
exert  upon  the  keratitis  itself.  It  should  be  given  in 
five-  to  ten-grain  doses,  three  times  a  day.  Salicylic 
acid  is  another  remedy  which  has  been  recommended, 
especially  in  herpes  zoster  ophthalmicus  (Leber);  but 
as  to  its  value  I  can  not  speak  from  experience. 

The  possibility  that  an  intractable  keratitis  of  the 
type  under  consideration  may  be  due  to  reflex  dental 
irritation  should  not  be  lost  sight  of.  Such  cases, 
doubtless,  are  not  common;  but  that  they  do  occur  I 
am  convinced.  "Dead"  teeth,  always,  it  would  seem, 
on  the  side  of  the  eye  affected  and  usuallv  in  the  upper 
jaw,  are  more  apt  to  produce  such  consequences.  If, 
therefore,  such  teeth,  or  others  badly  carious,  are  found 
to  be  present,  and  especially  if  they  are  painful  or 
sensitive  to  pressure,  they  should  be  extracted  without 
unnecessarv'  delay.  From  this  measure  I  have  seen 
benefit  result  too  often  to  leave  anv  doubt  in  my  mind 
as  to  the  propriety  of  resorting  to  it. 


DISEASES    OF    THE    CORNEA    AND    SCLERA. 


223 


In  this  connection  it  may  be  not  without  interest  to 
mention  that  I  have  met  with  two  cases  of  monocular 
paralysis  of  accommodation,  attended  by  mydriasis, 
which  were  clearly  due  to  reflex  dental  irritation,  and 
that  from  this  same  cause,  as  well  as  from  the  irrita- 
tion attendant  upon  phimosis  and  the  existence  of  ad- 
hesions between  the  prepuce  and  the  glans  penis,  I 
have  observed  clonic  spasm  of  the  orbicular  muscle  of 
the  lids. 

NON-SUPPURATIVE  KERATITIS. 

Interstitial  Keratitis  (Parenchymatous  Kerati- 
tis).— This  interesting  variety  of  corneal  inflammation, 
the  true  nature  of  which  was  first  recognized  by  that 
admirable  clinical  observer,  Mr.  Jonathan  Hutchinson, 
of  London,  occurs  only  as  a  result  of  inherited  syphilis. 
Other  sorts  of  deep  keratitis  may  resemble  it  in  ap- 
pearance; but  they  are  not  greatly  like  it  in  this  respect, 
and  are  entirely  unlike  it  in  all  other  respects.  In 
typical  cases  the  appearance  of  the  cornea — the  so- 
called  "ground-glass  cornea" — is  so  characteristic  that 
an  error  in  diagnosis  is  scarcely  possible.  (Plate  V,  Fig. 
2.)  On  the  other  hand,  in  less  severe  cases  it  is  not 
always  an  easy  matter  to  recognize  its  true  character. 

Although  occasionally  encountered  in  adults,  this 
type  of  keratitis  is  essentially  a  disease  of  childhood, 
and  commonly  occurs  between  the  ages  of  five  and 
fifteen.  Usually,  but  not  always,  it  aff'ects  both  eyes, 
generally  manifesting  itself  first  in  one  eye  and  sub- 
sequently, after  days  or  weeks,  attacking  the  other. 
It  is  seldom  attended  by  pain,  but  is  commonly  ac- 
companied by  pronounced  photophobia  and  lacrima- 
tion,  and  at  times  by  almost  uncontrollable  blepharo- 
spasm.    Depending   upon   the   extent   and   density  of 


224  PREVALENT    DISEASES    OF    THE    EYE. 

the  corneal  opacity,  vision  may  be  but  slightly  affected, 
or  may  be  reduced  to  mere  light  perception. 

Interstitial  keratitis  is  a  disease  of  the  substantia 
propria  of  the  cornea,  more  especially  of  its  deeper 
layers,  and  it  is  attended  not  only  by  dense  inflam- 
matory infiltration  but  by  the  formation  of  numerous 
fine  blood-vessels,  these  vessels  also  being  deeply  seated, 
and  not  upon  the  surface  of  the  cornea  as  we  find  them 
in  pannus  (Fig.  93).  This  feature,  of  new-vessel  forma- 
tion, varies  greatly  in  different  cases,  being  at  times  very 
pronounced  and  again  scarcely  perceptible  or,  it  may 
be,  entirely  absent.  When  it  is  marked,  it  gives  to  the 
cornea  a  salmon-pink  or  even  a  crimson  color.  There 
is  also  injection  of  the  conjunctival  vessels,  this  in- 
jection being  especially  noticeable  near  the  border  of 
the  cornea  and  particularly  at  points  where  the  kera- 
titis is  pronounced. 

The  inflammatory  infiltration  may  begin  at  the  mar- 
gin of  the  cornea  or  near  its  center.  In  the  former  case 
there  is  usually  an  ill-defined,  deep-seated,  nebulous 
opacity,  which  at  a  later  stage  may  assume  a  salmon- 
pink  appearance  from  the  formation  of  new  blood-ves- 
sels, as  has  just  been  mentioned.  Often  there  are  sev- 
eral such  areas  of  infiltration,  and  through  their  exten- 
sion and  confluence  the  whole  cornea  may  become 
involved.  When  the  inflammation  begins  centrally, 
the  opacity  may  be  of  the  same  diffused  and  ill-defined 
character,  or  there  may  be  many  small,  densely  opaque, 
deeply-seated  maculae.  The  epithelium  over  the  areas 
of  infiltration  loses  its  luster,  and  the  surface  of  the 
cornea  presents  an  appearance  like  that  produced  by 
breathing  upon  cold  glass.  The  "ground-glass"  effect 
is  exhibited  most  strikingly  in  those  cases  in  which  the 
infiltration  is  dense  and  the  formation  of  new  vessels  is 


DISEASES    OF    THE    CORNEA    AND    SCLERA. 


225 


slight.     There  is  no  tendency  to  tissue  necrosis,  and 
never  any  loss  of  corneal  substance  through  ulceration 
;or  suppuration. 

The  most  marked  characteristic  of  the  disease  is  its 


Fig.  93. —  Cross-section  of  cornea  in  interstitial  keratitis  (after  a  pre- 
paration of  Dr.  Nordenson)  (Fuchs).  The  stroma,  S,  of  the  cornea  shows 
an  infiltration,  which  begins  in  the  middle  layer,  and  keeps  on  increasing 
more  and  more  posteriorly,  so  that  the  deepest  layers,  i,  have  assumed  the 
aspect  of  a  granulating  tissue.  On  account  of  the  inequality  in  the  degree 
of  thickening  of  these  layers,  Descemet's  membrane,  D,  is  undulated;  upon 
its  endothelium  there  are  deposited  in  places  small  accumulations  of  round- 
cells,  r.  In  the  middle  and  deep  layers  of  the  cornea  we  see  the  transverse 
and  longitudinal  section  of  newly  formed  blood-vessels,  g,  g,  while  the 
most  anterior  layers,  and  also  Bowman's  membrane,  B,  and  the  epithelium, 
E,  are  normal. 

chronicity,  the  tedious  course  which  it  always  runs — a 
course  not  of  weeks,  but  of  many  months.  Because  of 
this,  it  is  especially  important  that  its  true  character 
should  be  recognized  at  the  outset,  in  order  that  those 

15 


226  PREVALENT    DISEASES    OF    THE     EYE. 

who  are  interested  in  the  welfare  of  the  patient  may 
know  what  is  in  store  for  them.  Although  the  sight  for  a 
considerable  time  may  be  seriously  impaired,  reduced,  it 
may  be,  to  mere  light  perception,  as  has  been  stated, 
the  ultimate  prognosis  is  decidedly  favorable.  This  is 
due  to  the  remarkable  manner  in  which  the  opacity  of 
the  cornea  slowly,  but  in  most  instances  almost  com- 
pletely, disappears.  In  no  other  variety  of  keratitis  do 
we  find  so  remarkable  a  change  in  this  regard.  How- 
ever, in  the  bad  cases,  in  which  the  corneal  opacity 
renders  inspection  of  the  deeper  structures  of  the  eye 
and  even  of  the  iris  impossible,  it  is  well  that  the  progno- 
sis should  be  guarded,  as  under  such  circumstances 
iritis  or  choroido-retinitis  may  occur,  without  our 
being  aware  of  it,  and  do  serious  damage  to  vision.  In 
some  instances,  too,  marked  and  permanent  impairment 
of  sight  may  result  from  persistence  ot  the  corneal 
opacity. 

The  occurrence  of  iritis  is  especially  to  be  deplored 
because,  owing  to  the  condition  of  the  cornea,  atropin 
is  very  imperfectly  absorbed,  and  it  is  often  impossible  to 
induce  the  pupil  to  dilate.  Even  w^hen  iritis  is  not  pres- 
ent the  pupil  frequently  remains  contracted  for  weeks 
in  spite  of  the  daily  application  of  a  strong  solution  of 
atropin,  and  finally  responds  to  its  influence  only  when 
the  keratitis  has  measurably  subsided.  The  occurrence 
of  pain,  which,  as  has  been  remarked,  is  not  a  usual 
symptom  of  this  type  of  corneal  inflammation,  points  to 
the  probable  development  of  iritis. 

Contrary  to  the  opinion  expressed  by  some  excellent 
authorities,  recurrent  attacks  of  interstitial  keratitis 
are  by  no  means  rare.  Not  very  infrequently,  after  an 
intermission  of  months  or  even  of  years,  I  have  seen 
the  disease  recur,  although  the  inflammation  is  apt  to 
be  less  severe  than  in  the  primary  attack. 


DISEASES    OF    THE    CORNEA    AND    SCLERA. 


227 


As  might  be  supposed,  other  evidences  of  the  consti- 
tutional taint  are  often  associated  with  the  eye  affection. 
The  notched  and  pegged  teeth — the  Hutchinson  teeth 
(Fig.  94) — and  the  physiognomy  characteristic  of  in- 
herited syphihs — the  sunken  nose-bridge,  the  prominent 
forehead,  and  the  fissured  mouth-angles — are  those  most 
frequently  observed  (Fig.  95),  while  periostitis  of  the 
long  bones  and  pronounced  labyrinthine  deafness  are 


Fig.  94.- — Hutchinson's  teeth  (Hutchinson):  i,  The  central  upper 
incisors  of  a  lad,  aged  fifteen  years,  the  subject  of  inherited  syphilis.  The 
teeth  are  short,  convergent,  narrow  from  side  to  side  at  their  edges,  and 
show  in  each  a  vertical  notch.  2,  These  teeth  present  similar  characters. 
The  notches,  however,  are  less  deep,  while  the  narrowing  from  side  to  side 
is  very  marked.  3,  The  upper  incisors  of  a  girl  aged  seventeen  years. 
There  is  a  wide  space  between  the  central  ones,  and  both  these  teeth, 
although  of  nearly  normal  length,  are  narrow,  and  show  deep  vertical  notches. 
As  is  usual,  the  lateral  incisors  are  more  nearly  normal  in  size  and  form. 
These  teeth  are  not  so  typical  as  those  shown  in  i  and  2. 

not  uncommon.  It  goes  without  saying,  therefore,  that 
in  every  case  of  supposed  interstitial  keratitis  such  signs 
of  inherited  lues  should  be  searched  for,  and  the 
family  history  should  be  inquired  into. 

Treatment. — Although  it  is  not  possible  by  any  ther- 
apeutic measures  to  cut  short  an  attack  of  interstitial 
keratitis,  there  can  be  no  question  as  to  the  value  of 
treatment,  when  instituted  early  and  persisted  in  system- 
atically.    Besides  lessening  the  discomfort  of  the  patient 


228 


PREVALENT    DISEASES    OF    THE     EYE. 


— the  photophobia,  lacrimation,  and  blepharospasm — it 
unquestionably  shortens  the  duration  of  the  disease; 
not  infrequently  prevents  the  second  eye  from  becoming 
involved;  renders  less  probable  the  extension  of  the 
inflammation  to  the  iris  and  deeper  tunics  of  the  eye,  and 
greatly  diminishes  the  likelihood  of  the  sight  being  per- 
manently impaired  through  the  persistence  of  the  cor- 


Fig.  95. — Physiognomy  characteristic  of  inherited  syphilis  (do  Schweinitz). 


neal  opacity.  Furthermore,  it  improves  the  general 
health  of  the  patient,  and  thus,  perhaps,  prevents  the 
occurrence  of  other  luetic  lesions. 

Locally,  the  treatment  consists  in  the  liberal  use  of 
atropin,  the  intermittent  application  of  hot  fomenta- 
tions, and  the  wearing  of  smoke-tinted  glasses.  The 
application  of  mercurial  ointment  to  the  forehead  and 


DISEASES    OF    THE    COR^vTEA    AND    SCLERA.  229 

temples  is  another  measure  which  at  times  is  useful. 
Owing  to  the  difficulty  commonly  experienced  in  dilat- 
ing the  pupil,  and  the  importance,  if  possible,  of  accom- 
plishing this,  the  atropin — which  in  this  affection  is  well 
borne,  even  by  young  children — should  be  used  in 
strong  solution,  usually  four  grains  to  the  ounce.  The 
hot  fomentations  are  indicated  especially  during  the 
earlier  and  more  acute  stage  of  the  disease,  and  seem  to 
afford  the  patient  measurable  relief.  A  convenient  way 
of  applying  heat  is  by  means  of  a  soft,  bird's-nest-shaped 
sponge,  which  should  be  dipped  frequently  into  hot 
water,  wrung  out,  and  applied  to  the  lids.  This  should 
be  done,  for  fifteen  minutes  at  a  time,  three  or  four  times 
a  day.  During  this  stage,  too,  the  atropin  should  be 
used  as  often  as  three,  or  even  four,  times  in  twenty-four 
hours.  Later  on,  when  the  ciliary  irritation  and  pho- 
tophobia have  subsided,  and  mydriasis  has  been  estab- 
lished, it  need  not  be  used  oftener  than  twice  daily, 
and  the  hot  fomentations  may  be  discontinued. 
Bandaging  the  eyes  is  detrimental,  and  should  not 
be  practised.  The  yellow  oxid  of  mercury  ointment, 
so  useful  in  phlyctenular  kerato-conjunctivitis,  con- 
trary to  what  might  be  expected  is  of  no  value  in 
this  affection.  It  is,  indeed,  recommended  by  some 
authorities;  but,  in  my  judgment,  it  does  more  harm 
than  good,  for  it  irritates  the  eye  and  increases  the 
discomfort  of  the  patient.  Dionin  has  been  used,  and 
it  is  claimed  with  good  effect;  but  it  seems  hardly  likely 
that  it  will  prove  of  much  value  in  so  chronic  an  affec- 
tion as  interstitial  keratitis. 

Mercury,  in  easily  borne  doses,  potassium  iodid,  and 
iron  are  the  constitutional  remedies  to  be  relied  upon, 
and  with  me  it  is  a  common  practice  to  administer  the 
three  in  combination.     Inunctions  of  mercurial  oint- 


230  PREVALENT    DISEASES    OF    THE     EYE. 

merit  are  recommended,  and  doubtless  are  valuable, 
though  it  has  been  my  habit  to  employ  them  only  in 
very  young  children  or  when  the  digestive  apparatus 
is  disordered. 

I  have  found  it  convenient  to  administer  mercurv  in 
the  form  of  the  biniodid,  giving  it  in  doses  of  4^  to  oV 
of  a  grain,  according  to  the  age  of  the  patient,  and 
always  prescribing  it  in  solution  with  the  addition  of 
potassium  iodid,  either  just  enough  of  the  latter  to 
render  the  mercury  soluble  or  in  such  quantity  as  to 
make  the  dose  from  one  to  five  grains.  The  syrup  of 
the  iodid  of  iron  often  is  added  to  this  solution,  or  is 
given  alone  or  in  combination  with  potassium  iodid. 
When  the  iodids  are  not  well  borne,  or  when  they  have 
been  given  for  a  considerable  time,  the  bichlorid  of 
mercury  is  substituted,  and  with  this  the  tincture  of 
chlorid  of  iron  is  frequently  combined.  Two  favorite 
prescriptions  with  me  are  the  following: 

R.  Hvdrarg.  biniodi ' gr-  i- 

Potas.  iodid gr-  v. 

Syr.  ferri  iodid OSS. 

Aquae 5  iiiss. 

B.  Kydrarg.  bichlorid gr-  i- 

Tinct.  ferri  chlorid §  ss. 

Aquae 5  iiiss. 

The  dose  of  each  is  a  teaspoonful,  well  diluted  with 
water,  three  times  a  day,  after  meals. 

As  fresh  air  and  sunlight  are  beneficial  to  the  patient's 
general  condition,  and  do  the  eves  no  harm,  he  should 
not  be  housed  or  kept  in  the  dark;  but,  in  spite  of  his 
photophobia,  should  be  encouraged  to  go  into  the  open 
air  and  take  plentv  of  out-of-door  exercise.  His  diet 
should  be  regulated  in  accordance  with  common-sense 


DISEASES    OF    THE    CORNEA    AND    SCLERA.  23 1 

rules,  and  condiments,  such  as  pepper,  mustard,  and 
the  Hke,  especially  should  be  interdicted.  The  near 
use  of  the  eyes,  as  in  reading,  writing,  and  sewing,  is 
impracticable  during  the  active  stage  of  the  disease,  and 
should  be  prohibited  throughout  the  long  period  of 
convalescence. 

The  absorption  of  the  corneal  opacity  is  necessarily 
a  slow  process,  and  as  this  is  true  especially  of  that  part 
of  it  which  is  situated  in  the  center  of  the  cornea  and 
overlies  the  pupil,  the  improvement  in  vision  is  distress- 
ingly slow.  Systematic  massage  of  the  eyes — rubbing 
the  cornea  gently  through  the  lids  with  the  finger-tip — 
which  can  be  done  best  by  the  patient  himself,  but 
should  not  be  practised  until  all  symptoms  of  irritation 
have  subsided,  probably  hastens  somewhat  the  clearing 
process. 

Not  infrequently  after  an  attack  of  interstitial  keratitis 
it  will  be  found  that  the  long-continued  inflammation 
has  produced  a  considerable  amount  of  corneal  astig- 
matism, and  if  this  is  not  wholly  irregular,  as,  unfortu- 
nately, too  often  is  the  case,  glasses  may  be  prescribed 
with  great  advantage. 

Pannitic  Keratitis  or  Pannus. — In  treating  of 
trachomatous  conjunctivitis  we  have  already  spoken 
of  this  variety  of  corneal  inflammation.  As  there 
stated,  it  is  a  usual  accompaniment  of  "granular 
lids,"  and  is  largely  the  result  of  the  mechanical  irrita- 
tion of  the  cornea  by  the  roughened  palpebral  con- 
junctiva. Because  of  the  greater  friction  exerted  upon 
the  cornea  by  the  upper  lid,  pannus  is  always  more 
pronounced  upon,  and  is  frequently  confined  to,  the 
upper  half  of  the  cornea.  Although  in  the  beginning 
only  the  epithelium  of  the  cornea  is  aff'ected,  a  loss  of 
luster  and  a  slight  roughening  being  observed,  the  super- 


232  PREVALENT    DISEASES    OF    THE     EYE. 

ficial  layers  of  the  substantia  propria  in  time  areinvolved. 
This  happens  often  in  consequence  of  the  formation  of 
ulcers  or  abscesses,  which  usually  are  the  result  of 
secondary  infections,  the  condition  of  the  cornea, 
denuded  of  its  epithelium,  being  such  as  to  favor 
bacterial  invasion. 

The  corneal  opacity  in  this  affection  is  less  uniform 
and  more  superficial  than  in  interstitial  keratitis,  and 
there  is  an  unevenness  of  the  surface  of  the  cornea  which 
is  not  present  in  the  latter  disease.  A  characteristic 
feature  of  pannitic  keratitis  is  the  formation  of  new 

blood-vessels  upon  the  cor- 
nea; but  these  vessels,  which 
grow  out  from  the  neighbor- 
ing conjunctiva,  are  coarse 
and  superficial,  and  bear  but 
little  resemblance  to  those 
which  are  observed  in  the 
keratitis  of  inherited  syph- 
ilis (Fig.  06). 

Fig.  96. —  Trachoma  with  pannus  1 

(Haab).  I^i    neglected    cases    the 

opacity  of  the  cornea  may  be 
so  great  as  to  render  the  iris  invisible,  and  to  reduce  sight 
to  little  better  than  light  perception.  While  the  diffuse 
opacity  due  to  uncomplicated  pannitic  keratitis  disap- 
pears in  large  measure  with  the  subsidence  of  the  inflam- 
mation of  the  conjunctiva  upon  which  it  depends,  the 
opacity  caused  by  intercurrent  ulcers  or  abscesses,  which 
is  more  dense  in  character,  is  apt  to  be  indelible.  Apart 
from  this,  however,  ulcers  or  abscesses  occurring  under 
such  circumstances,  though  they  are  frequently  attended 
by  severe  pain  and  by  an  aggravation  of  the  photo- 
phobia, lacrimation,  and  blepharospasm  that  are  the 
usual  accompaniments  of  trachomatous  conjunctivitis. 


DISEASES    OF    THE    CORNEA    AND    SCLERA.  2^3 

are  not  as  apt  to  produce  disastrous  consequences,  such 
as  perforation  into  the  anterior  chamber,  as  are  those 
which  develop  in  a  previously  healthy  cornea.  This  is 
because  of  the  increased  resisting  power  which  the  pan- 
nitic  cornea  derives  from  its  abnormal  vascularity. 

The  diagnosis  of  pannus  usually  is  not  difficult.  The 
coarse  and  superficial  character  of  the  new  blood- 
vessels, the  unevenness  of  the  corneal  surface,  the  lack 
of  uniformity  in  the  opacity  and  the  fact  that  it  is  com- 
monly limited  to  the  upper  half  of  the  cornea  indicate] 
its  true  nature,  and  should  lead  at  once  to  an  inspec 
tion  of  the  tarsal  conjunctiva  of  the  upper  lid,  the  ap- 
pearance of  which  in  trachoma  is  so  typical  as  to  place 
the  diagnosis  beyond  doubt. 

Treatment. — The  treatment  of  pannus  is  the  treatment 
of  trachoma,  and  this  has  been  fully  considered  already. 
It  may  be  well,  however,  to  say  that  the  employment  of 
atropin,  and  in  strong  solution,  is  especially  indicated 
when  intercurrent  ulcers  or  abscesses  occur,  and  that 
the  lotion  of  opium,  so  often  commended,  is  also  very 
useful  under  the  same  circumstances;  and,  further, 
to  mention  the  decided  benefit  that  results  in  some 
obstinate  cases  of  pannus,  which  do  not  respond  to  the 
usual  remedies,  from  the  performance  of  the  simple 
operation  of  canthotomy. 

This  operation,  w^hich  can  be  done  by  any  one  who 
has  a  modicum  of  surgical  skill,  does  good  by  lessening 
the  tension  of  the  upper  lid,  and  so  reducing  the  friction 
which  it  exerts  upon  the  cornea.  It  consists  in  a  length- 
ening of  the  palpebral  aperture  and  a  division  of  that 
part  of  the  external  canthal  ligament  w^hich  is  attached 
to  the  tarsal  cartilage  of  the  upper  lid.  It  is  performed 
as  follows:  With  a  pair  of  straight  scissors  the  external 
canthus,  at  one  cut,  is  divided  horizontally  outward  for 


234 


PREVALENT    DISEASES    OF    THE     EYE. 


adistanceof  8  or  lomm.  (Fig.97).  The  upper  lid  is  then 
put  upon  the  stretch,  and  the  superior  half  of  the  external 
canthai  ligament,  which  is  thus  made  tense,  is  cut  through 
with  the  scissors,  the  points  of  which  are  inserted  vertic- 
ally beneath  the  upper  lip  of  the  skin  wound.  The  first 
incision  will  have  divided  both  skin  and  conjunctiva, 
and  the  final  step  of  the  operation  consists  in  attaching 
the  edges  of  the  conjunctival  wound  to  those  of  the  skin 
w^ound  by  several  fine  sutures,  so  that  the  cut  edges  of 
the  skin  shall  not  unite  one  with  the    other  (Fig.  98). 


Fig.  97. —  Canthotomy.     The  incision  (modified  after  Czermak). 

For  this  purpose  I  employ  fine  black  silk  and  half-curved 
needles,  introducing  four  sutures,  two  to  bring  together 
the  upper  and  two  the  lower  lips  of  the  wound.  It  is 
well  to  make  the  horizontal  incision  rather  longer  than 
would  seem  to  be  necessary,  since  during  the  healing 
process  it  is  sure  to  shorten  somewhat.  The  sutures 
may  be  removed  after  three  or  four  days.  Before,  and 
for  a  time  after,  their  removal  the  outer  canthus  should 
be  anointed  with  borated  vaselin  or  cold-cream,  and 
any  tendency  to  grow  together  which  the  edges  of  the 


DISEASES    OF    THE    CORNEA    AND    SCLERA. 


235 


skin  wound  may  show  should  be  overcome  by  gently 
stretching  them  apart.  No  deformity  is  left  by  the 
operation;  indeed,  when  the  palpebral  aperture  is  preter- 
naturally  small,  as  is  sometimes  the  case  in  old 
trachoma,  a  distinct  improvement  in  the  appearance 
of  the  eye  results. 

Opacities  of  the  Cornea. — All  varieties  of  ker- 
atitis, as  has  been  stated,  are  attended  by  more  or  less 
pronounced    impairment   of  the   transparency    of  the 


Fig.  98. —  Canthotomy.     The  stitches  ready  to  be  tied  (Haab). 

cornea.  Often  this  loss  of  transparency  is  evanescent, 
but  not  infrequently,  especially  when  consequent  upon 
suppurative  keratitis,  it  is  permanent.  Permanent 
corneal  opacities  may  be  caused  also  by  interstitial,  and 
other  forms  of  deep,  keratitis,  by  wounds  of  the  cornea, 
by  severe  iritis,  and  by  protracted  disease  of  the  deeper 
tunics  of  the  eye;  while  one  common  form  of  opacity, 
the  well-known  arcus  senilis — due  to  colloid  degenera- 
tion of  the  superficial  layers  of  the  cornea — occurs 
spontaneously,  and,  it  may  be  remarked,  is  frequently 


236  PREVALENT    DISEASES    OF    THE    EYE. 

observed,  contrary  to  what  its  name  would  seem  to  in- 
dicate, in  persons  who  are  much  too  young  to  be  desig- 
nated as  "senile."  Apart  from  the  trivial  unsightli- 
ness  which  attends  it,  this  last-mentioned  variety  of 
corneal  opacity  causes  no  inconvenience,  and  does  not, 
as  was  once  supposed,  interfere  in  any  degree  with  the 
success  of  operations,  such  as  extraction  of  cataract, 
that  involve  section  of  the  corneal  limbus.  Undoubt- 
edly, the  largest  number  of  indelible  opacities  of  the 
cornea  are  the  result  of  ulcers,  the  density  of  the  opacity 
being  dependent  in  great  measure  upon  the  extent  to 


Fig.  99. —  Leucoma  resulting  frum  a  lime  burn  (Lawson). 

which  the  substantia  propria  has  been  destroyed  by  the 
ulcerative  process. 

According  to  their  density,  corneal  opacities  are  desig- 
nated as  nehulcB,  macidce,  or  leucomata  (Fig.  99),  and 
when,  in  consequence  of  an  ulcer  which  has  perforated 
into  the  anterior  chamber,  the  iris  is  attached  to  the 
corneal  scar,  we  have  a  leucoma  adherens  or  a  leucoma 
with  anterior  synechia  (Fig.  lOo). 

Marked  corneal  opacities  are  always  disfiguring;  but 
whether  they  cause  impairment  of  sight  or  not  depends 
less  upon  their  density  than  upon  their  location,  and 
upon  whether  they  are  attended  by  considerable  distor- 
tion of  the  curvature  of  the  cornea.  Thus,  a  very  slight 
nebulous  opacity,  scarcely  perceptible  by  simple  inspec- 
tion, if  situated  in  the  center  of  the  cornea,  in  the  line  of 


DISEASES    OF    THE    CORNEA    AND    SCLERA. 


'^Zl 


vision,  may  seriously  impair  the  sight;  whereas  even  a 
large  and  dense  leucoma  at  the  margin  of  the  cornea 
may  cause  no  visual  disturbance  whatever.  The  im- 
pairment of  sight  caused  by  such  faint,  central  nebulae, 
it  is  true,  is  due  less  to  the  slight  opacity  than  to  the 
marked  irregular  astigmatism  which  is  frequently  present 
under  such  circumstances,  and  which  leads  to  the 
formation  of  distorted  and  imperfect  retinal  images. 
In  the  same  way  corneal  scars,  which  are  not  in  the 
direct  line  of  vision,  may  give  rise  to  great  disturbance 


"m^m^r^ 


Fig.   loo. —  Leucoma  with  anterior  synechia. 


of  sight  if  they  are  attended  by  alteration  in  the  curva- 
ture of  the  cornea. 

A  superficial,  milk-white  opacity  of  the  cornea  results 
at  times  from  the  injudicious  use  of  collyria  containing 
lead  acetate.  This  happens  only  when  there  is  denuda- 
tion of  the  cornea  from  ulceration  or  traumatism,  and 
is  caused  by  the  deposit  of  an  insoluble  salt  of  lead 
upon  the  denuded  surface.  Because  of  its  density, 
such  an  opacity,  if  central,  produces  marked  disturb- 
ance of  vision.  To  avoid  the  risk  of  such  an  accident, 
solutions  of  "sugar  of  lead"  should   never   be  applied 


238  PREVALENT    DISEASES    OF    THE     EYE. 

to  the  eye  when  from  any  cause  loss  of  corneal  tissue 
has  taken  place. 

There  is  little  excuse  for  confounding  corneal  opacities 
with  opacities  situated  in  the  crystalline  lens,  and  yet, 
with  those  unfamiliar  with  diseases  of  the  eye,  this  is 
an  error  of  not  very  infrequent  occurrence.  If  by 
simple  daylight  inspection  the  location  of  the  opacity  is 
not  evident,  it  can  be  determined,  beyond  doubt,  by  the 
aid  of  oblique  illumination,  which,  therefore,  should 
always  be  employed  under  such  circumstances. 

TreaUnent. — Little  can  be  done  to  promote  the  ab- 
sorption of  corneal  opacities  of  longstanding.  Nature, 
as  has  been  indicated,  often  accomplishes  a  great  deal, 
especially  when  the  opacity  is  the  result  of  inflammatory 
infiltration  unattended  by  necrosis  ot  true  corneal  tissue. 
Massage, — rubbing  the  cornea  through  the  upper  lid 
with  the  finger-tip, — if  employed  perseveringly,  may 
do  some  good,  provided  the  opacity  is  not  too  dense  and 
is  not  of  too  long  standing.  In  connection  with  massage 
an  ointment  of  yellow  oxid  of  mercury  (gr.  j  to  vaselin 
oj)  may  be  used.  Subconjunctival  injections  of  salt 
solution  (one  per  cent,  to  five  per  cent.)  are  not  without 
value  in  suitable  cases,  that  is  to  say,  in  opacities  of 
not  too  long  duration,  and,  under  such  circumstances, 
dionin  (in  five  per  cent,  solution),  which  acts  in 
much  the  same  way  as  the  salt  injections  do — by  stim- 
ulating the  lymph  currents  of  the  eye — is  of  undoubted 
value.  The  chances  of  improvement  are  better  in 
children  than  in  adults. 

When  the  opacity  overlies  the  pupil,  but  more  espe- 
cially when  the  sight  of  both  eves  is  impaired,  consider- 
able improvement  in  vision  may  be  obtained  by  an 
iridectomy,  the  artificial  pupil  being  placed  behind  a 
clear  or  relatively  clear  portion  of  the  cornea.     Con- 


DISEASES    OF    THE    CORNEA    AND    SCLERA.  239 

spicuous  leucomata  are  sometimes  tattooed  with  India 
ink,  in  order  to  render  them  less  unsightly. 

Staphyloma  of  the  Cornea  (Anterior  Staphy- 
loma).— Occasionally  as  a  result  of  a  penetratingwound 
or  of  extensive  and  deep  ulceration  of  the  cornea, 
but  usually  in  consequence  of  more  or  less  complete 
corneal  necrosis  occurring  during  the  course  of  a  puru- 

■.  lent  (gonorrheal)  conjunctivitis,  an  irregular  protrusion 
of  the  anterior  segment  of  the  eyeball  occurs.  When  this 
protrusion  is  confined  to  a  limited  area  of  the  cornea, 
as  is  more  apt  to  be  the  case  v/hen  it  arises  from  one  of 
the  two  first-mentioned  causes,  it  is  known  as  partial 
staphyloma;  when  it  mvolves  the  whole  cornea,  or,  as 
sometimes  happens,  the  anterior  portion  of  the  sclera 
as  well,  it  is  known  as  total  staphyloma. 

In  total  staphyloma  the  protrusion,  which  may  be 
inconsiderable  or  so  great  that  the  lids  cannot  be  closed 
over  it,  is  irregularly  globular  in  shape  and  occasionally 

I  somewhat  lobulated,  is  bluish-white  in  color,  and 
frequently  exhibits  upon  its  surface  several  coarse, 
tortuous  veins  (Plate  VI,  Fig.  i).  The  protuberant  tissue 
consists  mainly  of  the  iris  reinforced  by  newly  formed 
connectivetissue,  some  remnants  of  the  cornea,  perhaps, 
being  found  incorporated  with  its  base  (Fig.  loi).  The 
development  of  the  staphyloma  is  due  to  the  inability 
of  this  improvised  tunic  to  resist  the  pressure  exerted 
by  the  intraocular  fluids.  In  partial  staphyloma  the 
walls  of  the  ectasia  are  made  up  of  corneal,  iridic 
and  newly  formed  scar  tissue,  and  the  protuberance 
is  commonly  near  the  margin  of  the  cornea.  When 
the  whole  cornea  is  involved  in  the  staphylomatous 
process  vision  is  necessarily  reduced  to  mere  perception 
of  light;  but  when  the  defect  is  partial,  good  vision 
may  be    retained,  though,  owing  to  the  distortion  of 


240  PREVALENT    DISEASES    OF    THE     EYE. 

the  corneal  curvature  and  the  displacement  of  the  pupil 
so  often  present,  this  is  usually  not  the  case. 

Because  of  its  poor  resisting  power,  the  staphyloma- 
tous  tissue  is  not  infrequently  the  seat  of  recurrent  attacks 
of  inflammation.  This  happens  especially  in  those 
cases  of  total  staphyloma  in  which  the  protuberance  is 
so  great  as  not  to  receive  the  protection  of  the  lids. 
In  such  cases,  too,  accidental  rupture  of  the  thinned 
walls  of  the  staphyloma  is  not  uncommon.     Infection 


Fig.  loi.  —  Cross-section  of  a  total  staphyloma,  the  result  of  exten- 
sive necrosis  of  the  cornea  (schematic)  (Fuchs).  Only  the  marginal  por- 
tions, c,  of  the  cornea  are  preserved,  and  these  are  still  partially  infiltrated. 
Between  them  bulges  the  iris,  which  is  driven  strongly  forward  and  which 
consequently  is  thinned  so  that  the  pigment,  i,  upon  its  posterior  surface 
shines  through  it  and  gives  the  prolapse  a  blackish  hue.  The  pupil,  p, 
is  closed  by  a  membrane.  The  space,  h,  between  the  iris  and  the  lens 
is  the  enlarged  posterior  chamber.  Of  the  anterior  chamber  only  the  shal- 
low, slit-like,  annular  space,  v,  is  left.  This  no  longer  communicates  any- 
where with  the  posterior  chamber  (seclusio  pupillae). 

of  the  deeper  tunics  of  the  eye,  leading  to  purulent 
panophthalmitis,  is  another  accident  which  may  occur 
at  any  time. 

Treatment. — In  its  incipiency  the  development  of  a 
staphyloma — of  a  partial  staphyloma  more  especially — 
may  be  arrested,  in  some  instances,  by  the  continuous 
support  of  a  not  too  tightly  applied  pressure  bandage. 
At  this  stage,  too,  a  partial  abscission  of  the  ectasia  or 
a  well-placed  iridectomy  may  be  very  effective.  In  total 
staphyloma  restoration  of  vision  is  impracticable,  and 


PLATE  VI. 


S 


X 


^-H^... 


Fig.   I. — Total  Staphyloma  (after  Sichel). 


iUfoha  Li 


Fig.  2. — Episcleritis. 


'7'V.^^4^^*c:.    _^, 


^.'lAcob.M 


Fig.  3. — Serous  Iritis  (I'veitis). 


DISEASES    OF    THE    CORNEA    AND    SCLERA,  24I 

enucleation  of  the  eye  is  commonly  indicated,  not  for 
its  cosmetic  effect  only,  but  because  it  eliminates  all 
the  possible  complications  mentioned  as  apt  to  occur. 
In  children,  too  young  to  wear  an  artificial  eye,  abscis- 
sion may  be  practised  in  accordance  with  the  method, 
recommended  by  Knapp,  the  wound  being  closed  by 
bringing  together,  with  four  or  five  stitches,  the  pre- 
viously undermined  conjunctiva. 

In  partial  staphyloma,  if  the  vision  is  good  and  the 
ectasia  shows  no  tendency  to  increase,  surgical  inter- 
ference is  usually  contraindicated;  but,  on  the  other 
hand,  if  the  vision  is  poor,  and  especially  if  the  staphy- 
loma is  progressing,  an  iridectomy  may  do  much  good. 


Fig.    102. —  Conical  cornea  {de  Schweinitz). 

not  only  by  its  direct  effect  upon  vision,  but  by  reducing 
the  intraocular  tension,  and  so  staying  the  increase  of 
the  staphyloma. 

Conical  Cornea  (Keratoconus).^In  this  condi- 
tion, which  is  comparatively  rare  and  therefore  calls 
for  but  brief  mention,  the  cornea  gradually  assumes, 
usually  without  considerable  loss  of  transparency,  a 
distinctly  conoidal  shape  (Fig.  102).  This  change 
in  the  form  of  the  cornea  gives  rise  to  a  high  grade 
of  myopia,  attended  by  excessive  symmetrical  aberra- 
tion of  the  eye,  in  consequence  of  which  vision  is  greatly 
impaired. 

Treatment. — In  the  lower  grades  of  this  anomaly 
16 


242  PREVALENT    DISEASES    OF    THE     EYE. 

carefully  adjusted  glasses  are  helpful.  In  the  higher 
grades,  especially  if  the  condition  is  progressing,  an 
effort  should  be  made  to  reduce  the  protrusion  by 
cautiously  cauterizing  the  apex  of  the  cone  with  the 
galvanocautery,  care  being  taken  not  to  perforate  the 
cornea.  This  delicate  procedure,  it  should  be  remarked, 
requires  for  its  successful  performance  especial  skill  and 
experience. 

Tumors  of  the  cornea  are  exceedingly  rare,  and 
so  do  not  demand  our  consideration. 

Traumatic  lesions  of  the  cornea,  which  are  of 
common  occurrence,  are  treated  of  in  Chapter  XIII, 
devoted  to  injuries  of  the  eye. 

DISEASES  OF  THE  SCLERA. 

The  tough  and  non-vascular  sclera,  or  sclerotic  coat 
of  the  eye,  is  not  often  the  seat  of  diseased  processes. 
In  deep  keratitis  the  neighboring  sclera  is  at  times 
involved,  the  condition  being  known  as  kerato-scleritis, 
and  in  syphilitic  irido-cyclitis  (especially  in  the  negro 
race)  the  anterior  portion  of  the  sclera  may  become 
implicated,  and  a  staphylomatous  condition  may  result 
from  the  softening  and  thinning  which  it  undergoes. 

Scleritis  (Sclerotitis;  Sclero-conjunctivitis). — 
Inflammation  confined  to,  or  having  its  starting-point 
f,  in,  the  sclera  is  usually  of  rheumatic  or  gouty  origin. 
Two  varieties  of  scleritis  are  encountered — an  acute, 
diff'use  inflammation,  which  is  aptly  described  by  the 
name  sclero-conjunctivitis,  and  a  more  persistent  form, 
in  which  the  inflammation  is  circumscribed. 

Sclero-conjunctivitis. — In  this  type  of  scleritis  the 
inflammation  is  often  capricious  and  fleeting  in  char- 
acter, attacking  one  eye  to-day,  and  after  twenty-four 
or  forty-eight  hours  disappearing  from  this  eye  only  to 


DISEASES    OF    THE    CORNEA    AND    SCLERA.  243 

manifest  itself  in  the  other.  It  is  characterized  by 
marked,  general  injection  of  the  conjunctival  and  sub- 
conjunctival vessels,  and  is  usually  attended  by  pro- 
nounced pain,  photophobia,  and  lacrimation. 

In  chronic  scleritis  (Fig.  1 03)  the  injection  and  in- 
flammation are  confined  to  a  limited  area  of  the  sclera, 
usually  near  the  corneal  margin,  and  the  hyperemic 
vessels  are  finer  and  more  deeply  seated,  in  consequence 
of  which  the  affected  area  presents  a  dusky  red  or  pur- 
plish appearance.  Pain  and  photophobia  are  less  con- 
spicuous in  this  variety,  but  involvement  of  the  cornea 
or  iris  is  more  apt  to  occur. 


Fig.   103. —  Scleritis  (Haab). 

Acute   diffuse  scleritis  or  sclero-conjunctivitis  is  to  . 
be  distinguished  from  simple  conjunctivitis  by  the  pain  j 
and   the   greater  photophobia   and   lacrimation  w^hich  j 
attend  it,  and  by  the  fact  that  it  is  commonly  monocular. 
Its  association  with  other  manifestations  of  a  rheumatic 
or  gouty  diathesis  affords  additional  evidence  of  its  real 
character.     Except  by  the  course  of  events,  it  is  not  to 
be  distinguished  from  the  incipient  stage  of  luetic  or 
rheumaticjritis — the  stage,  often  observed,  in  which, 
as  yet,  the  iris  is  neither  muddy  nor  swollen,,  and  in 
which    the    pupil    dilates    fully    and    symmetrically   to 
atropin. 

Treatment. — In  the  acute  form  of  the  disease  atropin 


244  PREVALENT    DISEASES    OF    THE    EYE. 

in  Strong  solution,  and  moist  heat  (hot  water  or,  better 
still,  the  lotion  of  opium,  applied  hot)  are  indicated,  and, 
internally,  sodium  salicylate  in  liberal  doses,  supple- 
mented by  a  brisk  purgative.  In  the  circumscribed 
form,  atropin  and  the  lotion  of  opium  are  called  for, 
while  potassium  iodid,  sodium  salicylate,  lithium,  and 
colchicum  are  the  constitutional  remedies  apt  to  accom- 
plish the  greatest  good. 

Episcleritis. — This  is  an  affection  of  not  un- 
common occurrence,  and  consists  in  a  circumscribed 
inflammation,  usually  monocular,  of  the  episcleral 
connective  tissue,  in  which  the  superficial  layers  ot  the 
sclera  are  frequently  involved  (Plate  \T,  Fig.  2).  The  in- 
flamed area,  which  is  always  adjacent  to  the  corneal  lim- 
bus,  is  somewhat  elevated,  and  of  a  dark  red  or  purplish 
color.  Pain  is  not  a  usual  symptom,  but  photophobia 
and  an  irritability  of  the  eye,  unfitting  it  for  near  work, 
are  commonly  present.  This  affection,  which  is  rarely 
encountered  in  children,  and  is  commoner  in  women 
than  in  men,  does  not  respond  satisfactorily  to  treat- 
ment, and,  still  worse,  when  seemingly  cured,  is  prone 
to  recur,  it  may  be  at  the  same  spot  or  upon  some  other 
part  of  the  pericorneal  region. 

Episcleritis  at  times  bears  a  close  resemblance  to 
phlyctenular  conjunctivitis,  and  it  might  be  confounded, 
also,  with  the  bulbar  variety  of  vernal  catarrh.  Its 
course,  however,  is  more  protracted  than  the  former 
disease  and  much  less  protracted  than  the  latter. 
Moreover,  there  is  no  tendency  to  ulceration,  as  in 
phlyctenular  conjunctivitis,  and  no  itching,  as  in  vernal 
catarrh. 

It  is  often  impossible  to  assign  a  cause  for  episcleritis; 
but  there  can  be  no  doubt  that  in  many  instances  it  is 
dependent  upon  a  rheumatic  or  goutv  diathesis. 


DISEASES    OF    THE    CORNEA    AND    SCLERA. 


245 


Treatment. — This  is  much  the  same  as  in  circum- 
scribed scleritis.  Atropin  with  boracic  acid,  the 
strength  of  the  solution  depending  upon  the  ciHary 
irritation  and  photophobia  present,  or  holocain  with 
boracic  acid  (holocain  muriatis,  gr.  i;  acid,  boracic, 
gr.  x;  aq.  destil.,  5i,  to  be  dropped  into  the  eye  every 
three  or  four  hours),  are  the  most  useful  local  remedies, 
to  which  may  be  added  the  lotion  of  opium,  if  there  is 
pain  or  marked  ciliary  irritation.  The  yellow  oxid  of 
mercury,  so  efficacious  in  phlyctenular  conjunctivitis, 
is  contraindicated.  Potassium  iodid  in  moderate  doses, 
and  frequently  in  combination  with  syrup  of  the  iodid 
of  iron,  is  the  constitutional  remedy  I  have  found  most 
beneficial.  Other  useful  remedies  are  sodium  salicylate, 
and  lithium,  preferably  in  the  form  of  the  natural 
mineral  water.  Regulation  of  the  diet  and  of  the 
bowels  is  also  important. 


CHAPTER  \II. 
DISEASES  OF  THE  IRIS  AND  CILIARY  BODY. 

DISEASES  OF  THE  IRIS. 

Iritis. — Iritis,  or  inflammation  of  the  iris,  is  one  of 
the  common  afi^ections  of  the  eve,  and  it  is  one  with 
which  it  is  especially  important  the  general  practi- 
tioner should  be  familiar.  It  arises  from  a  variety  of 
causes,  may  attack  one  or  both  eyes,  and,  though  almost 
always  amenable  to  treatment  if  recognized  in  its  incep- 
tion and  judiciously  managed,  it  is  apt  to  impair  the 
sight  more  or  less  seriously,  and  permanently  damage 
the  integrity  of  the  eye  if  allowed  to  run  its  course  un- 
checked, or  if  improperly  or  only  tardily  treated.  It  is 
essential,  therefore,  that  its  true  character  should  be 
recognized  at  the  outset,  and  that  the  requisite  thera- 
peutic measures  should  be  resorted  to  without  delay. 

The  diagnosis  of  inflammation  of  the  iris  is  commonly 
not  a  difficult  matter,  and  the  indications  for  its  treat- 
ment are  usually  plain.  Nevertheless,  it  is  frequently 
confounded  with  other  forms  of  inflammation  of  the 
eye,  and  for  this  reason  improperly  treated.  In  conse- 
quence of  this,  or  because  of  the  ignorance  or  indiff"er- 
ence  of  those  whom  it  attacks,  it  is  by  no  means  an  un- 
common  cause  of  blindness. 

The  existence  of  iritis  is  to  be  suspected  whenever, 
without  increase  of  intraocular  tension  or  other  evident 
cause,  pam  in  and  around  the  eye,  usually  worse  at 
night,  is  complained  of,  and  is  accompanied  by  peri- 
corneal   subconjunctival    injection    and    a    contracted 

246 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY.  247 

pupil.  This  concourse  of  symptoms  does  not  neces- 
sarily indicate  the  presence  of  iritis,  but  it  is  distinctly 
suggestive,  and  should  lead  to  a  careful  search  for  other 
evidences  of  its  existence.  A  dull,  lack-luster  appear- 
ance of  the  iris,  with  appreciable  change  of  color  and 
more  or  less  swelling  of  its  tissue;  immobility  of  the 
pupil,  and  perhaps  loss  of  its  circular  form;  diminished 
transparency  of  the  aqueous  humor,  and  frequently  of 
the  cornea  as  well,  with  consequent  indistinctness  of 
vision;  adhesions  between  the  margin  of  the  pupil  and 
the  anterior  capsule  of  the  lens,  which,  however,  are 
frequently  not  evident  until  a  mydriatic  has  been  used; 
and  in  severe  cases  a  grayish  opacity  of  the  pupil  from 
the  deposition  of  an  organized  exudate  upon  the  lens 
capsule,  are  the  other  changes  which  should  be  sought 
for,  and  which,  if  found,  establish  the  diagnosis  beyond 
question. 

In  examining  a  case  of  suspected  iritis  the  use  of  "ob- 
lique illumination"  is  of  great  assistance,  since  it  en- 
ables one  to  detect  slight  changes  in  the  cornea  and  in 
the  tissue  of  the  iris,  and  in  many  cases  to  discover  ad- 
hesions between  the  ins  and  lens,  which  can  not  be  seen 
by  simple  inspection.  If,  however,  any  doubt  remains 
as  to  the  existence  of  iritis  after  this  method  of  examina- 
tion has  been  employed,  a  weak  solution  of  atropin  (gr. 
ss.-i  to  5i)  or  of  homatropin  (gr.  iv  to  5i)  or  euphthal- 
min  (gr.  viii  to  oi)  should  be  dropped  into  the  eye, 
when,  if  iritis  is  present,  the  pupil  will  almost  certainly 
dilate  in  an  irregular  manner,  showing  points  of  ad- 
hesion between  its  margin  and  the  lens  capsule. 

The  character  of  the  vascular  injection  ot  the  eyeball, 
while  helpful,  is  not  always  an  entirely  trustworthy  guide 
in  the  differential  diagnosis  of  iritis.  When,  however, 
it  is  most  marked  around  the  corneal  margin,  is  of  a 


248  PREVALENT    DISEASES    OF    THE    EYE. 

pinkish  rather  than  a  brick-red  color,  and  the  vessels 
involved  are  for  the  most  part  small,  and  radiate  more 
or  less  regularly  from  the  margin  of  the  cornea  toward 
the  equator  of  the  globe,  we  may,  at  least,  conclude  that 
structures  deeper  than  the  conjunctiva  are  involved  in 
the  inflammatory  process,  and  that  the  existence  of  iritis 
is  probable. 

Among  the  causes  of  iritis,  syphilis  deserves  the  most 
prominent  place.  Traumatism  is  another  frequent 
cause,  and  not  only  when  the  iris  itself  is  involved  in  the 
injury,  but  also  when  the  cornea,  lens,  or  ciliar}^  body 
is  wounded.  Rheumatism  and  gout,  diabetes,  and 
the  acute  infectious  diseases  also  deserve  mention  in 
this  connection,  and  gonorrhea,  though  an  infrequent 
cause, occasionally  gives risetoit,theocularinflammation 
having  the  same  relation  to  the  urethral  disease  that 
gonorrheal  arthritis  has.  Iritis  may  also  be  a  conse- 
quence of  inflammation  of  other  structures  of  the  eye, 
as,  for  instance,  abscess  or  perforating  ulcer  of  the 
cornea. 

There  is  also  another  cause  of  iritis  to  which  I  am 
disposed  to  attach  importance,  and  which  I  believe  to 
be  an  essential  factor  in  the  production  of  several  appar- 
ently distinct  varieties  of  the  disease.  I  refer  to  an 
influence  transmitted  through  sympathetic  or  ''trophic" 
nerves,  which  is  frequently  reflex  in  character,  and  is 
probably  dependent  upon  structural  changes  in  gray 
nerve  matter,  either  in  the  cerebral  ganglia  themselves, 
or  in  the  ganglia  connected  with  the  fifth  nerve,  or  in 
both.  It  is  such  an  influence  as  this,  I  believe,  that 
determines  the  development  of  sympathetic  iritis,  the 
iritis  which  is  frequently  found  associated  with  herpes 
zoster  ophthalmicus,  that  which  occasionally  follows 
malarial  attacks,  and   probably   also  certain   cases   of 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY. 


249 


serous  iritis.  In  this  category  belong  also  those  cases 
of  iritis  which  rightfully,  I  think,  have  been  ascribed  to 
reflex  dental  and  reflex  uterine  irritation,  as  well  as 
certain  intractable  forms  of  irido-keratitis,  that  not 
infrequently  are  accompanied  by  anesthesia  of  the  cor- 


Fig.  104. —  Vertical  section,  showing  total  posterior  synechia  (Fuchs). 
The  iris  is  adherent  by  its  posterior  surface  to  the  anterior  capsule  of  the 
lens  and  also  to  the  anterior  surface  of  the  ciliary  body.  The  posterior 
chamber  consequently  is  obliterated  and  the  anterior  chamber  deepened 
at  its  periphery',  h;  at  this  spot  the  iris  is  strongly  retracted  and  at  the  same 
time  is  here  the  most  thinned  through  atrophy.  The  exudate  connecting  the 
iris  with  the  lens  also  stretches  as  a  thin  membrane,  p,  across  the  pupil. 
The  exudate,  s,  springing  from  the  ciliary  body,  envelops  the  pos- 
terior surface  of  the  lens  and  by  its  shrinking  draws  the  ciliar}'  processes 
toward  the  center.  As  a  result  of  this  a  separation  of  the  ciliarj-  body, 
c,  from  its  bed  has  already  taken  place  below,  and  in  the  intermediate  space 
are  seen  the  disjoined  lamellae  of  the  suprachoroid  membrane,  a.  The 
pigment  epithelium,  /,  of  the  ciliary  processes  has  undergone  proliferation. 
At  the  lower  part  of  the  cornea  there  is  a  zonular  opacity,  g.  The  lens  is 
swollen  and  is  opaque  throughout;  there  is  no  hard  undisintegrated  nu- 
cleus {i.  e.,  it  is  a  soft  cataract). 


nea.  Obstinacy  and  intractability  are  the  common 
characteristics  of  these  several  varieties  of  iritis,  and  in 
the  pathological  changes  which  they  exhibit,  especially 
the  tendency  of  the  entire  posterior  surface  of  the  iris 
to  become  glued  to  the  lens  capsule  (Fig.  104),  a  condi- 
tion   seldom  met  with    even   in   the    worst   cases,   for 


250  PREVALENT    DISEASES    OF    THE     EYE. 

example,  of  syphilitic  iritis,  there  are  also  striking  re- 
semblances.* 

The  consequences  of  a  severe  attack  of  iritis  which 
has  been  neglected  or  has  been  improperly  treated  are 
disastrous  to  the  integrity  of  the  eye  in  several  v^^ays. 
In  the  first  place,  especially  in  syphilitic  iritis,  other 
structures  of  the  eve,  for  example,  the  ciliary  body, 
choroid,  retina,  and  lens,  are  liable  to  become  involved 
in  the  inflammatory  process,  and  may  suffer  irreparable 
damage  (Fig.  105).  Again,  the  pupil  may  be  closed 
or  obstructed  by  an  organized  membrane  (occlusion), 
so  that  vision  is  reduced  to  mere  perception  of  light;  or 
the  iris  may  become  adherent  to  the  anterior  surface 
of  the  lens,  at  its  pupillary  margin  only  (exclusion),  or 
throughout  its  whole  extent  (complete  posterior 
synechia)  (Fig.  104).  In  the  two  former  conditions 
operative  interference  may  accomplish  great  good;  in 
the  latter,  whatever  plan  of  treatment  is  adopted,  the 
prognosis  is  much  less  favorable,  and  in  time  the  deeper 
tunics  are  apt  to  suffer  and  the  lens  to  lose  its  trans- 
parency. Sympathetic  inflammation  of  the  fellows-eye 
is  another  result  of  neglected  iritis,  which,  though 
not  of  frequent  occurrence,  happens  often  enough  to 
deserve  mention. 

Although  there  are  so  many  causes  of  iritis,  there  are, 
strictly  speaking,  but  three  different  kinds  of  iritis 
— plastic  trttis,  purulent  iritis,  and  serous  iritis  (Descem- 
etitis,  uveitis).  The  first  named  variety,  plastic  iritis, 
characterized  by  the  formation  of  an  exudate,  rich  in 

*  The  author  reaHzes  that  to  express  such  an  opinion  as  this  re- 
garding the  genesis  of  inflammation  is  to  run  counter  to  the  teachings 
of  modern  pathology;  but  he  is  not  convinced  that  the  last  word 
has  yet  been  spoken  upon  this  subject.  (Compare  foot-note  on  page 
259-) 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY. 


251 


cells,  which  tends  to  become  organized,  is  by  far  the 
most  comprehensive.     It  includes  most  cases  of  syphil- 


Fig.  105.  —  Meridional  section  through  ciliary  region,  including  the 
iris  and  part  of  the  cornea  and  lens  (Fuchs):  C,  Co  nea;  pe,  pc,  pigmented 
and  non-pigmented  cells  of  the  pars  ciliaris  retina?;  L,  lens;  M,  ciliary 
muscle;  r,  its  radiating,  Mu,  its  circular  fibers;  ci,  anterior  ciliary  artery; 
s,  canal  of  Schlemm;  c,  /,  anterior  surface  of  iris;  break  at  cr;  sp, 
sphincter  pupilla;;  p,  edge  of  pupil;  P,  ciliary  process;  /;,  pigment  Hning 
iris,  partly  separated  at  v;  a,  blood-vessel;  z^,  2,,  fibers  of  suspensory  liga- 
ment, enclosing  spaces  i,  i\    k,  lens-capsule;  /,  ligamentum  pectinatum. 


itic,    of  rheumatic    and   gouty,   of  gonorrheal,   and  of 
sympathetic  iritis.     Many  cases  of  traumatic  iritis  are 


252  PREVALENT    DISEASES    OF    THE     EYE. 

also  of  this  character,  and  so  are  most  of  those  which 
have  been  spoken  of  as  due  to  ''trophic"  nerve  in- 
fluence. 

Purulent  iritis  is  less  common.  It  is  usually  the  re- 
sult of  penetrating  v/ounds  of  the  eyeball,  or  of  opera- 
tions in  which  the  globe  is  opened,  and  is  almost  always 
due  to  the  presence  of  a  pyogenic  micro-organism.  It 
may  also  follow  severe  suppurative  inflammation  of 
the  cornea. 

Serous  iritis  or,  more  correctly,  uveitis,  is  a  disease 
bv  no  means  of  rare  occurrence,  yet  it  is  one  about  the 
pathology  of  which  we  have  much  to  learn.  There  is 
no  doubt  but  that  the  iritis  is  usually  only  a  part  of 
an  inflammatory  process  which  involves  the  entire 
uveal  coat.  In  some  instances  it  seems  to  be  de- 
pendent upon  a  rheumatic  diathesis,  and  in  othefs, 
as  has  already  been  intimated,  upon  a  reflex  or  "trophic  " 
nerve  influence,  while,  oftener  than  not,  it  is  impossible 
to  assign  a  cause  for  it.  The  distinguishing  characteris- 
tics of  serous  iritis  (Plate  VI,  Fig.  3),  which,  fortunately, 
is  rarely  a  binocular  affection,  are  that  the  pupil  is  not 
contracted,  as  in  other  forms  of  inflammation  of  the 
iris;  that  posterior  svnechi.Te  rarely  occur;  that  there  is 
a  disposition  to  increased  intraocular  tension;  that  the 
vitreous  humor  is  often  diff^usely  clouded  or  contains 
numerous  floating  opacities;  and,  most  typical  of  all, 
that  there  is  commonly  a  deposit  of  minute  opaque  dots, 
of  a  yellowish-gray  color,  upon  the  inner  surface  of  the 
cornea.  These  dots,  which  are  due  to  the  deposition 
of  round  cells  and  coagulated  fibrin  upon  the  corneal 
endothelium  (Fig.  106),  are  usually  arranged  in  a 
triangular  shape,  the  base  of  the  triangle  being  at  the 
lower  margin  of  the  cornea,  while  its  apex  reaches  up  to, 
or  may  even  extend  beyond,  the  center  of  the  cornea. 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY. 


253 


Occasionally  the  affection  exhibits  a  mixed  type,  and  the 
characteristic  dots  upon  the  corneal  endothelium,  etc., 
are  attended  by  a  disposition  to  the  formation  of  pos- 
terior synechias.  It  usually  runs  a  protracted  course, 
and  responds  far  from  satisfactorily  to  treatment. 
Unless  the  tension  assumes  a  glaucomatous  character, 
pain  is  not  often  complained  of,  and  there  is  an  absence 
of  pronounced  photophobia.  Owing  to  the  opacity  of 
the  vitreous  humor  and  the  condition  of  the  cornea. 


Fig.  106. — Section  showing  deposit  of  round  cells  and  coagulated 
fibrin  upon  the  inner  surface  of  the  cornea  in  uveitis.  Magnified  140  X  i 
(Fuchs).  The  posterior  surface  of  the  cornea,  C,  is  covered  by  Descemet's 
membrane,  D,  and  the  endothelium,  e.  The  latter,  which  as  a  whole  is 
of  normal  character,  is  wanting  at  the  spot  where  the  deposit,  P,  is  situated. 
This  deposit  consists  of  an  accumulation  of  cells  with  interspersed  pigment 
granules  which  are  partly  free  and  partly  inclosed  in  the  round  cells.  In 
the  place  where  no  deposits  are  situated  the  posterior  surface  of  the  cornea 
is  covered  by  a  layer  of  exudation  consisting  of  two  strata,  an  anterior  one, 
b,  composed  of  round  cells,  and  a  posterior  one,  /,  formed  of  coagulated 
fibrin. 

vision  during  the  height  of  the  attack  may  be  reduced  to 
little  better  than  light  perception.  Serious  and  per- 
manent impairment  of  sight  may  result,  if  the  increase 
of  intraocular  tension  has  been  persistent  and  pro- 
nounced enough  to  injure  the  optic  nerve,  or  if,  as 
not  infrequently  happens,  the  retina  has  suffered  in 
consequence  of  the  general  uveitis. 

All  varieties  of  plastic  iritis  (Plate  VII,  Fig.  l),  as  has 
been  stated,  are  characterized  by  a  tendency  to  the  tor- 


254 


PREVALENT    DISEASES    OF    THE     EYE. 


mation  of  anorganized exudate, but  this  tendency  ismuch 
more  marked  in  some  than  in  others.  It  is  especially 
so  in  sympathetic  iritis,  in  the  iritis  of  herpes  zoster 
ophthalmicus,  and,  in  fact,  in  all  those  forms  of  iritis 
which  appear  to  be  due  to  "trophic"  nerve  influence. 
In  syphilitic  and  in  rheumatic  iritis  this  tendency  usu- 
ally manifests  itself  by  the  formation  of  adhesions 
between  only  the  pupillary  margin  of  the  iris  and  the 
capsule    of    the  lens    (Fig.   107) ;   but  in  sympathetic 


Fig.   107. — Annular  posterior  synechia,   with  occlusion  of  pupil  and  iris 
bombe  (Deaver). 


and  other  allied  forms  of  iritis  a  felt-like  exudation 
forms  upon  the  posterior  surface  of  the  iris,  causing  it 
to  adhere  throughout  its  whole  extent  to  the  lens,  and 
the  pupil  is  commonly  occluded  by  similar  material 
(see  Fig.  104).  Under  such  circumstances,  too,  project- 
ing portions  of  the  anterior  surface  of  the  iris  may  be- 
come adherent  (without  ulceration)  to  the  inner  sur- 
face of  the  cornea,  giving  rise  to  anterior  synechia?. 

Syphilitic  iritis,  which  is  usually  attended  by  severe 
pain,  and  by  marked    photophobia    and    lacrimation. 


PLATE   VU. 


"x 


6n 


Fig.   I. — Plastic    Iritis.     Pupil  partly  dilated    by  atropin,   showing  two 
posterior  synechije. 


FiG.  2. — Inflammatory  Glaucoma. 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY.  255 

commonly  manifests  itself  during  the  secondary  stage  of 
the  disease,  in  association  with  the  macular  eruption 
and  the  appearance  of  condylomatous  growths.  Less 
frequently  it  occurs  in  the  tertiary  stage.  It  is  also 
met  with  in  inherited  syphilis,  sometimes  in  infancy, 
sometimes  even  as  a  prenatal  affection,  but  oftenest 
between  the  ages  of  seven  and  fifteen  years,  in  connec- 
tion with  an  outbreak  of  interstitial  keratitis.  About 
fifty  per  cent,  of  all  cases  of  iritis  are  due  to  syphilis, 
inherited  or  acquired. 

A  pathognomonic,  but  by  no  means  constant,  feature 
of  syphilitic  iritis  is  the  development  upon  the  anterior 
surface  of  the  iris  of  yellowish  or  reddish-brown  nod- 
ules, which  project  forward  into  the  anterior  chamber, 
and  sometimes  even  press  against  the  cornea.  Usually 
there  are  not  more  than  one  or  two  present;  but  they 
may  be  so  numerous,  and  of  such  size,  as  to  fill  the  an- 
terior chamber.  They  occur  more  frequently  in  the 
iritis  which  develops  during  the  secondary  stage  of  the 
disease,  and  are  then  of  the  nature  of  condylomata 
(Fig.  108);  those  met  within  the  iritis  of  tertiary  syphilis 
are  gummatous  in  character.  Hence  the  former  variety 
of  iritis  is  sometimes  designated  iritis  condylomatosa,  and 
the  latter  variety,  iritis  gummosa.  They  may  undergo 
absorption,  or  may  disappear  through  fatty  or  puru- 
lent degeneration.  The  inflammation  of  the  iris  tissue 
being  more  intense  over  the  area  which  corresponds  to 
their  base,  we  find  here  a  special  tendency  to  the  forma- 
tion of  adhesions  to  the  lens  capsule.  All  the  varieties 
of  iritis  may  be  complicated  by  ^'hypopyon,"  though  it  is 
more  common  in  the  purulent  and  syphilitic  types. 
It  is  due  to  the  deposition  from  the  aqueous  humor  of 
leukocytes  or  of  round  cells  and  fibrin,  and,  as  a  rule, 
undergoes  absorption  slowly.     As  the  deposit  may  or 


2s6 


PREVALENT    DISEASES    OF    THE    EYE. 


may  not  consist  of  leukocytes  the  term,  as  commonly 
employed,  is  inexact. 

Sympathetic  Iritis. — Although  exceptionally  sym- 
pathetic ophthalmitis  manifests  itself  as  a  neuro- 
retinitis  or  choroido-retinitis,  it  very  generally  begins 
as  an  iritis  or  an  irido-cyclitis,  and,  even  in  the  rare 
instances  in  which  the  inflammation  commences  at  the 
posterior  pole  of  the  eve,  it  soon  extends  to  the  iris  and 
ciliary  bodv  unless   promptly  brought   under  control. 


Fig.   io8. —  Syphilitic   iritis,    showing   condyloma.     Pupil   dilated   by   atro- 

pin  (Haab). 


It  is  not  inappropriate,  therefore,  to  consider  this  affec- 
tion in  connection  with  other  forms  of  iritis. 

There  are  but  few  diseases  of  the  eye  in  which  the 
prognosis  is  more  grave,  and  in  which  treatment  is  of 
less  avail,  than  in  sympathetic  ophthalmitis.  It  is  usu- 
allv  the  result  of  a  severe  traumatic  lesion,  commonly 
of  a  penetrating  w^ound,  of  the  primarily  affected  or 
"exciting  eye."  Wounds  involving  the  iris  and  ciliary 
body,   and   those   complicated    by  the   lodgment   of  a 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY.  257 

foreign  body  in  the  interior  oi  the  eye,  are  especially 
apt  to  give  rise  to  it.  It  may  also  be  induced  by  severe 
and  protracted  inflammation  of  the  iris,  ciliary  body, 
and  choroid  of  non-traumatic  origin.  It  is  interesting 
to  note  that  a  sympathetic  inflammation  leading  to  com- 
plete destruction  of  sight  may  be  brought  about  by  an 
injured  or  diseased  eye  which  still  retains  a  useful 
amount  of  vision.  Another  point  of  interest  is  that 
the  disease  has  no  definite  period  of  "incubation,"  if 
we  may  use  the  expression,  that  the  interval  between 
the  receipt  of  the  injury  or  the  occurrence  of  the  inflam- 
mation in  the  exciting  eye  and  the  development  of  the 
sympathetic  aff"ection  in  the  fellow-eye  may  vary  from 
two  or  three  weeks  to  very  many  years. 

Usually,  but  not  always,  the  outbreak  of  an  attack  of 
sympathetic  inflam?nation  is  preceded  by  a  period, 
which  may  be  brief  or  very  prolonged,  of  sympathetic 
irritation  in  the  sympathizing  eye.  This  condition, 
which  is  unattended  by  structural  changes,  and,  there- 
fore, is  to  be  sharply  difi^erentiated  from  sympathetic 
ophthalmitis,  is  characterized  by  the  existence  of  pho- 
tophobia and  lacrirnation  and  by  a  "weakness"  or 
irritability  of  the  eye,  which  renders  it  incapable  of 
near  work,  especially.  Diminution  of  accommodative 
power  and  a  tendency,  upon  slight  provocation,  to 
hyperemia  of  the  conjunctival  vessels  are  also  frequently 
present.  All  these  symptoms,  constituting  sympathetic 
irritation,  it  should  be  remarked,  disappear  promptly 
upon  the  removal  of  the  exciting  cause,  that  is  to  say, 
upon  the  enucleation  of  the  primarily  aflPected  eye. 

Unlike  sympathetic  irritation,  sympathetic  inflamma- 
tion^ when  once  established,  though  it  may  be  favorably 
influenced,  is  seldom  cut  short  by  the  removal  of  the 
exciting  eye.  On  the  contrary,  though  detected  in  its 
-1 


258  PREVALENT    DISEASES    OF    THE    EYE. 

incipiency  and  combated  by  every  known  therapeutic 
means,  it  commonly  leads,  after  a  prolonged  course 
attended  by  much  suffering,  to  complete  destruction 
of  sight  and  ultimately  to  atrophy  of  the  eyeball.  The 
inflammation  is  usually  of  a  plastic  character,  and  when 
it  involves  the  iris  gives  rise,  as  has  been  mentioned 
already,  to  the  formation  of  a  felt-like  exudate,  which 
occludes  the  pupil,  and  glues  the  entire  posterior  surface 
of  the  iris  to  the  lens  capsule  (see  Fig.  104).  The 
choroid  and  retina  are  soon  implicated,  and  in  this  way 
light  perception  is  lost. 

As  to  the  manner  in  which  the  inflammation  is 
lighted  up  in  the  sympathizing  eye,  and  as  to  the  role 
played  by  the  exciting  eye  in  the  process,  there  is  still 
much  uncertainty  and  great  difference  of  opinion.  The 
soundness  of  the  more  prevalent  view  that  the  inflamma- 
tion in  the  second  eye  is  caused  by  micro-organisms 
which  have  migrated  to  it  from  the  primarily  affected 
eye,  probably  along  the  lymph-channels  of  the  optic 
nerves,  has  certainly  yet  to  be  demonstrated;  and,  it 
may  be  observed,  there  are  many  features  in  the  clinical 
history  of  the  disease  that  militate  against  this  view. 
On  the  other  hand,  there  is,  it  seems  to  me,  much  evi- 
dence to  support  the  older  theory  that  sympathetic 
ophthalmitis  is  a  neuropathic  affection;  that  the  inflam- 
matory changes  in  the  sympathizing  eye  are  the  product 
of  a  reflex  influence  which  is  provoked  by  the  intense 
and  continued  irritation  of  the  ciliary^  nerves  in  the 
primarily  affected  eye,  and  that  the  peculiar  character- 
istics of  this  inflammation — its  intractability  and  its 
malignancy — are  the  result  solely  of  this  reflex  influence, 
and  not  of  especially  virulent  bacterial  action.  It  is 
in  accordance  with  this  view  that  I  have  spoken  of 
sympathetic  iritis  as  belonging  to  the  group  of  "  trophic" 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY.  259 

nerve  inflammations  ot  the  eye,  along  with  herpes 
zoster  ophthalmicus,  reflex  dental,  and  postmalarial 
iritis  and  keratitis,  etc. 

As  I  long  ago  pointed  out,*  it  is  probable  that  the 
inflammatory  manifestations  in  the  sympathizing  eye 
are  preceded  by,  and  are  dependent  upon,  pathological 
changes  in  the  ganglia  connected  with  the  fifth  nerve 
and  in  the  brain-centers  which  have  to  do-  with  the 
metabolism  of  the  eye.  These  changes,  it  seems  prob- 
able, are  not  unlike  those  which  occur  in  the  gasserian 
ganglion  and  in  the  ganglia  upon  the  posterior  roots  of 
the  spinal  nerves  in  herpes  zoster.  {'  In  this  connection 
it  is  interesting  to  note  the  close  resemblance  which 
the  iritis  of  herpes  zoster  ophthalmicus  bears  to  that 
which  we  meet  with  in  sympathetic  ophthalmitis.  Like 
the  latter,  it  is  obstinate  and  intractable,  and  in  each 
the  iris  shows  the  same  tendency  to  become  extensively 
adherent  to  the  lens  capsule — a  tendency  which,  as 
has  been  stated,  is  commonly  not  manifested  in  the 
iritis  of  syphilis  or  of  rheumatism. 

Some  authors  describe  a  variety  of  inflammation  of 
the  ins  which  they  call  '^spongy  iritis ^     It  is,  however, 

*  In  a  paper  upon  the  "Pathogeny  of  Sympathetic  Ophthalmia," 
"Archives  of  Ophthalmology,"  Vol.  XIII,  No.  i,  1884. 

t  As  a  result  of  their  painstaking  investigation  of  the  pathology 
of  herpes  zoster.  Head  and  Campbell  ("Brain,"  Vol.  XXIII,  p.  353) 
assert  that  these  changes  consist  of  "an  acute  interstitial  inflamma- 
tion accompanied  by  necrosis  of  the  ganglion  cells."  It  is  of  interest 
to  note,  further,  that  they  could  find  no  evidence  that  bacteria  play 
any  part  in  either  the  ganglion  or  skin  lesions,  and  that  they  regard 
the  latter  as  being  the  result  of  "intense  irritation  of  cells  in  the 
ganglion  which  normally  subserve  the  function  of  pain,"  and  not 
as  due  to  "disturbance  of  special  trophic  nerves."  If  these  conclusions 
are  correct,  their  important  bearing  upon  the  etiology  of  sympathetic 
inflammation  is  obvious.  (For  a  fuller  consideration  of  this  ques- 
tion, see  a  paper  by  the  author  upon  "The  Genesis  of  Sympathetic 
Ophthalmitis,"  published  in  the  "Journal  of  the  American  Medical 
Association,"  Jan.  28,  1905.) 


260  PREVALENT    DISEASES     OF    THE    EYE 

only  a  type  of  the  plastic  variety,  in  which  there  occurs  a 
low  form  of  plastic  exudation  in  the  anterior  chamber, 
that  presents  a  cyst-like  appearance,  and  might  be 
mistaken  for  a  dislocated  lens.  Such  cases  are  com- 
monly of  rheumatic  origin. 

A  c hro?i  1  c  fonn  of  plastic  zr;//j- isoccasionallymetwith, 
in  which  the  inflammatory  symptoms  are  but  slightly 
marked.  It  is  often  associated  with  a  rheumatic  or 
gouty  diathesis,  and  shows  a  disposition  to  recurrence. 
Points  of  adhesion  between  the  iris  and  lens  are  apt  to 
take  place  before  the  true  nature  of  the  attack  is  dis- 
covered, as  it  develops  insidiously,  and  is  unattended 
by  pain  or  other  symptoms  calculated  to  alarm  the 
patient  and  induce  him  to  seek  medical  advice. 

Treatment. — In  the  treatment  of  iritis  in  general  the 
indications  are  to  control  and  overcome  the  inflamma- 
tion as  quickly  as  possible,  and,  by  the  use  of  a  mydri- 
atic, to  keep  the  pupil  widely  dilated,  so  that  adhesions 
shall  not  form  between  the  posterior  surface  of  the  iris 
and  the  lens  capsule.  Nearly  always  constitutional 
as  well  as  local  measures  are  called  tor.  The  most 
important  local  remedy  is  atropin.  Four  grains  to  the 
ounce  (about  one  per  cent.)  is  the  strength  of  the  solution 
of  atropin  usually  employed.  In  the  different  varieties 
of  plastic  and  purulent  iritis  it  must  be  used  freely, 
the  frequency  of  the  applications  being  determined 
chiefly  by  the  state  of  the  pupil  and  the  amount  of 
ciliary  neuralgia  and  photophobia.  When  there  are 
recent  pupillary  adhesions,  which  we  hope  to  break  up 
(for  we  can  usually  accomplish  this,  unless  the  bands 
are  firm  and  broad),  an  instillation  every  hour  may  be 
required,  or  even,  for  a  short  time,  several  instillations 
an  hour  may  be  permissible.  Such  frequent  applica- 
tions, however,  can  not  be  long  continued  without  the 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY.  261 

constitutional  effects  of  the  drug  becoming  manifest, 
and,  as  cases  of  marked  individual  susceptibility  to  the 
action  of  belladonna  are  occasionally  met  with,  due 
caution  should  be  exercised  in  using  atropin  in  this  man- 
ner. Ordinarily,  four  to  six  applications  a  day  are 
sufficient.  In  serous  iritis  atropin  should  not  be  used 
so  frequently  or  in  such  strong  solution,  since  in  this 
affection  the  pupil  yields  readily  to  its  influence,  and 
moreover,  owing  to  the  tendency  to  increased  intra- 
ocular tension  which  characterizes  this  disease,  there  is 
danger  that  its  too  liberal  use  may  precipitate  a 
glaucomatous  condition. 

Especially  in  plastic  iritis,  dionin,  used  in  conjunction 
with  atropin,  is  often  beneficial,  since  it  not  only  lessens 
the  pain,  and  promotes  the  absorption  of  inflammatory 
products,  but  increases  the  mydriatic  effect  of  the 
atropin.  It  may  be  used  as  often  as  three  times  a  day 
in  five  per  cent,  solution. 

Occasionally  individuals  are  met  with  in  whom  atro- 
pin fails  to  produce  a  mydriatic  effect,  and  others  in 
whom  it  greatly  irritates  the  conjunctiva,  a  few  applica- 
tions producing  a  conjunctivitis,  which  may  be  attended 
by  an  erythematous  inflammation  of  the  lids  and  cheek. 
Under  such  circumstances  hyoscyamin  hydrobromate 
or  duboisin  sulphate  may  be  substituted  for  atropin. 
As  these  mydriatics,  especially  the  latter,  are  more  apt  to 
produce  constitutional  effects  when  applied  to  the  eve 
than  atropin,  greater  caution  is  required  in  their  use. 
Two  grains  to  the  ounce  will  usually  be  a  strong 
enough  solution  of  either  of  these  to  employ,  and  this 
should  not  be  applied  more  than  three  or  four  times  a 
day. 

In  many  cases  of  iritis  no  other  local  treatment  than 
the  employment  of  a  mydriatic  is  required;    but,  when 


262  PREVALENT    DISEASES    OF    THE     EYE. 

the  inflammation  is  of  severe  type,  the  appHcation  of 
three  or  four  leeches  to  the  temple  may  accomplish 
good,  and,  when  there  is  severe  pain,  much  relief  is  often 
experienced  from  the  use  of  a  lotion  of  opium  (ext.  opii, 
gr.  x.-xv;  aquae,  5iv)  or  of  belladonna  (ext.  bella- 
donnae,  gr.  xv;  aquae,  5iv),  which  should  be  applied 
to  the  closed  lids  more  or  less  constantly  upon  a  pad  of 
gauze  or  soft  linen.  The  application  in  the  same  way, 
for  half  an  hour  at  a  time  several  times  a  day,  of  water 
as  hot  as  can  be  borne  is  also  a  useful  expedient  under 
the  same  circumstances.  In  obstinate  cases,  more 
especially  those  of  syphilitic  origin,  it  is  well  to  supple- 
ment the  use  of  constitutional  remedies  by  the  applica- 
tion to  the  forehead  and  temples,  two  or  three  times  a 
day,  of  mercurial  ointment,  to  which  extract  of  bella- 
donna or  extract  of  opium  may  be  added  in  the  pro- 
portion of   5j-ij  to  Sj. 

Of  constitutional  remedies,  the  most  valuable  are 
mercury,  potassium  iodid,  and  the  salicylates.  If  to 
this  list  are  added  quinin,  which  is  especially  useful  in 
purulent  iritis;  opium,  which  seems  not  only  to  control 
the  pain,  but  favorably  to  influence  the  inflammation; 
pilocarpin  hydrochlorate,  which  is  useful  especially  when 
there  is  increased  intraocular  tension;  and  some  brisk 
purgative  combination  which,  as  a  rule,  should  contain 
calomel,  it  will  comprise  all  the  drugs  that  are  likely  to 
be  needed  in  treating  any  of  the  varieties  of  the  disease. 
A  supplemental  list  of  less  important  but  at  times  useful 
remedies  would  include  arsenic,  colchicum,  lithia,  iron 
and  the  Turkish  bath. 

In  acute  plastic  iritis,  whether  of  specific  or  non- 
specific origin,  sodium  or  lithium  salicylate,  given  in 
liberal  doses  (gr.  x  to  xv  every  two  or  three  hours, 
according  to  the    susceptibility    of  the  patient"),  is,  on 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY.  263 

the  whole,  the  most  promptly  efficacious  remedy  that 
we  have.  In  many  cases,  and  especially  in  those  of 
rheumatic  origin,  it  not  only  relieves  the  pain  very 
quickly,  but  hastens  the  resolution  of  the  inflammation 
and  promotes  the  absorption  of  effused  material. 

In  syphilitic  iritis,  whether  the  disease  be  inherited 
or  acquired,  mercury  in  some  form  is  usually  demanded. 
It  is  also  our  chief  reliance  in  sympathetic  iritis,  and  is 
more  useful  than  anything  else — unless  it  be  potassium 
iodid — in  the  iritis  of  herpes  zoster  ophthalmicus  and 
in  theother  "  trophic  "  nerve  varieties.  In  the  acute  stage 
of  syphilitic  iritis  it  should  be  administered  liberally, 
and  in  such  shape  as  to  impress  the  system  promptly. 
Salivation  is  to  be  avoided,  but  in  severe  cases  we 
must  not  stop  far  short  of  it.  Small  doses  of  calomel, 
frequently  repeated  (gr.  ^  every  hour,  or  gr.  ss.  every 
three  hours),  supplemented,  if  necessary,  by  inunctions 
of  mercurial  ointment,  afford  the  best  means  of  accom- 
plishing the  desired  result.  There  seem  to  be  no  contra- 
indications to  the  administration  of  sodium  salicylate 
and  mercury  at  the  same  time,  and  I  have  obtained 
good  results  in  this  way.  Opium  may  be  given  if  the 
pain  is  severe,  or  if  a  purgative  effect  is  produced  by  the 
mercury.  In  subacute  cases,  or  when  the  symptoms  are 
less  urgent,  biniodid  of  mercury,  in  doses  varying  from 
gr.  Jj  to  gr.  ^2,  may  be  given  three  times  a  day.  This 
is  a  very  efficacious  and  convenient  method  of  admin- 
istering mercury,  and  salivation  is  less  apt  to  occur  than 
when  calomel  is  employed.  It  may  be  given  in  tablet 
triturates  or  pills,  or  preferably  in  solution  in  water,  a 
small  quantity  of  potassium  iodid  being  added  to  render 
the  mercury  soluble.  When  a  prolonged  course  of 
mercury  is  required  this,  or  the  protoiodid,  is  decidedly 
the  best  form  in  which  to  administer  it. 


264  PREVALENT    DISEASES    OF    THE    EYE. 

Potassium  iodic!  is  valuable  in  rheumatic  iritis,  and 
it  may  also  advantageously  supplement  the  use  of  mer- 
cur}'  in  svphilitic  iritis.  In  serous  iritis  it  is  the  most 
efficacious  remedy  that  we  possess,  but  its  good  effects 
are  not  always  manifest  until  it  is  given  in  liberal  doses. 

In  sympathetic  iritis  the  prognosis  is  grave,  whatever 
treatment  may  be  adopted.  The  most  essential  thing 
is  that  it  should  be  commenced  with  the  least  possible 
delay.  Although,  as  has  been  indicated,  radically  dif- 
ferent views  are  held  as  to  the  etiology  of  sympathetic 
ophthalmitis,  it  is  generally  agreed  that  the  chances 
of  controlling  the  inflammation  in  the  sympathizing 
eye  are  increased  by  the  removal  of  the  exciting  eye. 
The  condition  of  this  eye,  therefore,  should  be  carefully 
determined,  and  if  it  is  blind  or  so  nearly  blind  that 
useful  vision  wnth  it  is  impossible,  although  at  the  time  it 
may  be  quiescent  and  apparently  free  from  inflamma- 
tion, it  should  be  enucleated  without  a  moment's  un- 
necessary delay.  On  the  other  hand,  if  there  is  a 
reasonable  probability  that,  with  or  without  operation, 
a  useful  degree  of  vision  may  be  retained  in  this  eye, 
it  is  best  not  to  sacrifice  it;  for  it  should  be  borne  in 
mind  that  instances  have  occurred  in  which  the  sight  of 
the  sympathizing  eye  was  entirely  lost  while  serviceable 
vision  was  retained  in  the  primarily  affected  eye.  This 
question,  whether  or  not  to  enucleate  an  eye  which, 
though  not  itself  sightless,  has  caused  and  is  promoting 
the  development  of  sympathetic  inflammation  in  its 
fellow,  is  one  of  the  most  perplexing  which  fall  to  the 
lot  of  the  ophthalmic  surgeon  to  decide,  and  it  is  cer- 
tainly one  which  no  one  without  his  especial  training 
should  attempt  to  decide. 

Mercury  given  liberally,  by  the  mouth  and  by  inunc- 
tion, so  as  to  impress  the  system  rapidly,  and,  it  may 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY.  265 

be  added,  given  persistently,  is  the  remedy  which  lias 
been  chiefly  relied  upon  to  combat  sympathetic  inflam- 
mation, in  whatever  form  it  may  manifest  itself.  At 
a  later  stage  potassium  iodid  may  be  administered  with 
benefit.  GifFord,  in  several  cases,  has  obtained  surpris- 
ingly satisfactory  results  from  the  administration  of 
heroic  doses  of  sodium  salicylate — "150  to  200  grains 
in  the  course  of  the  waking  hours."*  His  experience 
certainly  seems  to  call  for  further  experimentation  in 
this  direction. 

In  purulent  iritis,  which,  as  has  been  said,  usually 
follows  wounds  of  the  eye  or  operations  upon  it,  and  is 
frequently  accompanied  by  purulent  infiltration  of  the 
cornea,  the  free  administration  of  quinin  sulphate  off'ers 
the  best  prospect,  though  not  a  very  promising  one, 
of  success.  Pilocarpin  hydrochlorate,  which  seems  to 
be  as  efficacious  when  administered  by  the  mouth  as 
when  introduced  into  the  system  by  the  hypodermic 
method,  is  sometimes  useful  in  cases  of  serous  iritis,  in 
W'hich  the  tension  of  the  globe  is  high;  and  in  any  of  the 
other  varieties,  if  this  condition  obtains  or  if  there  is 
cloudiness  of  the  vitreous  humor,  it  may  be  administered 
with  advantage.  I  have  found  it  convenient  to  pre- 
scribe it  in  a  solution  of  the  strength  of  gr.  j  to  5i-  Ten 
drops  of  this  solution,  containing  one-sixth  of  a  grain 
of  the  salt,  is  the  commencing  dose,  to  be  taken  bv  the 
mouth,  once  a  day.  According  to  the  effect  produced, 
the  dose  is  increased  by  adding  each  day  two  or  three  to 
the  number  of  drops  administered.  In  any  severe 
attack  of  iritis  an  active  cathartic  may  be  given  with  ad- 
vantage at  the  commencement  of  the  treatment.  A 
very  efficacious  one  is  the  combination  of  two  to  five 

*  "Diseases  of  the  Eye,  Nose,  Throat  and  Ear,"  Posey  and 
Wright,  p.  396. 


266  PREVALENT    DISEASES    OF    THE     EYE. 

grains  of  calomel,  two  grains  ot  scammony,  and  six  of 
powdered  rhubarb,  already  commended. 

When  the  iritis  is  dependent  upon  a  gouty  diathesis, 
colchicum  and  the  preparations  of  lithium  are  use- 
ful; and  in  the  iritis  which  sometimes  follows  malarial 
attacks,  and  in  that  which  accompanies  ophthalmic 
shingles,  arsenic,  in  the  form  of  Fowler's  solution, 
may  be  prescribed  with  benefit.  The  daily  use  of 
the  Turkish  bath  is  commended  by  Bull  as  a  valuable 
remedy  in  arthritic  iritis. 

In  the  management  of  every  case  of  iritis  the  question 
arises  whether  the  patient  should  be  confined  to  the 
house  during  the  continuance  of  the  attack.  Undoubt- 
edly, in  acute  cases,  and  especially  when  the  inflamma- 
tion is  severe,  this  should  be  done  if  practicable.  It  is 
very  rarely  necessary,  however,  that  he  should  be  shut 
up  in  a  dark  room.  With  a  shade  and  with  dark  glasses 
(London-smoke  coquilles),  he  may  safely  be  allowed  the 
freedom  of  the  house.  This  makes  the  treatment  much 
less  irksome  to  the  patient,  and  does  not  in  the  least  re- 
tard the  cure.  In  subacute  cases,  and  even  in  acute 
cases  when  there  is  but  little  pain  or  photophobia,  the 
patient  need  not  be  confined  to  the  house,  unless,  of 
course,  the  weather  be  unpropitious.  Indeed,  most 
patients  with  iritis  are  treated  successfully  as  "out- 
patients," being  seen  by  the  medical  attendant  either  at 
his  office  or  at  his  hospital  clinic. 

Surgical  interference  is  rarely  required  during  the 
active  stage  of  iritis.  There  are,  however,  some  excep- 
tions to  this  rule,  as,  for  instance,  in  serous  iritis,  when 
the  supervention  of  glaucomatous  symptoms  may  de- 
mand the  prompt  performance  of  an  iridectomy.  To 
remedy  the  consequences  of  iritis,  however,  and  to  pre- 
vent  recurrent   attacks,   operations   upon   the   eye   are 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY.  26/ 

frequently  called  for.  When,  after  an  attack  of  iritis, 
a  few  slender  bands  of  adhesion  between  the  margin  of 
the  pupil  and  the  lens  are  left,  probably  no  ill  conse- 
quences will  result  therefrom,  and  for  such  a  condition 
no  operation  is  required.  If,  however,  as  happens  not 
infrequently  in  neglected  cases,  the  margin  of  the  pupil 
is  completely  glued  to  the  surface  of  the  lens,  an  iridec- 
tomy should  be  performed  without  unnecessary  delay,  for 
soon  the  iris  will  be  bulged  forward  by  the  accumulation 
of  fluid  behind  it  (see  Fig,  107),  and  will  undergo 
atrophy,  while  at  the  same  time  the  deeper  structures 
of  the  eye  will  suffer  from  the  consequent  disturb- 
ance of  their  nutrition.  When,  though  not  completely 
adherent,  the  margin  of  the  pupil  is  attached  to  the 
lens  by  several  broad  bands,  an  iridectomy  may  be  re- 
quired, since  recurrent  attacks  of  inflammation  are  not 
infrequently  induced  in  consequence  of  the  irritation 
caused  by  the  traction  of  these  bands  during  the 
muscular    movements    of  the    iris. 

When  the  pupil  is  closed,  or  is  occluded  by  an  organ- 
ized exudate,  an  iridectomy  is  positively  indicated,  and, 
by  yielding  a  clear  artificial  pupil,  may  restore  almost 
normal  vision  to  a  nearly  blind  eye.  If,  however,  the 
pupillary  occlusion  is  attended,  as  it  sometimes  is  after 
the  more  severe  types  of  iritis,  with  adhesion  of  nearly 
the  entire  posterior  surface  of  the  iris  to  the  lens  capsule 
(see  Fig.  104),  the  outcome  of  an  iridectomy  is  apt  to 
be  much  less  satisfactory;  for  under  such  circumstances 
it  is  very  difficult  to  obtain  a  clear  pupil,  since  it 
frequently  happens  that  the  iris  tissue  is  so  friable  that 
it  can  not  be  drawn  out  by  the  forceps,  or  the  muscular 
coat  only  yields  to  the  traction,  while  the  pigment  coat 
remains  attached  to  the  lens  capsule.  There  is  great 
danger,  too,  that  the  new  pupil,  if  we  are  so  fortunate 


268  PREVALENT    DISEASES    OF    THE     EYE. 

as  to  secure  one,  will  become  occluded  as  a  result  of 
the  inflammation  arising  from  the  performance  of  the 
iridectomy. 

DISEASES  OF  THE  CILIARY  BODY. 

Cyclitis. — Inflammation  of  the  ciliary  body,  or 
cyclitis,  though  of  common  occurrence,  is  seldom  met 
with  as  a  disease  per  se.  Usually  it  is  but  part  of  a 
more  general  inflammation  of  the  uveal  tract — of  a 
choroiditis  it  may  be,  though  oftener  it  occurs  in  associ- 
ation with  iritis;  indeed,  it  is  present  in  most  cases  of 
severe  iritis,  especially  those  of  syphilitic  origin. 

In  cyclitis,  as  in  iritis,  the  inflammation  may  be  of 
plastic,  or  it  may  be  of  purulent  or  serous,  type.  Plastic 
cyclitis  is  commonly  due  to  syphilis  or  to  rheumatism; 
it  also  occurs,  and  in  its  worst  form,  in  sympathetic 
ophthalmitis.  Purulent  cyclitis  usually  arises  from 
penetrating  wounds  of  the  ciliary  region  or  of  the  cornea 
and  iris.  It  may  occur  also  as  a  complication  in  opera- 
tions, such  as  extraction  of  cataract,  which  involve 
opening  of  the  eveball.  It  is  always  a  consequence  of 
infection,  and  it  leads  commonly  to  a  general  suppura- 
tive inflammation  of  the  eye — panophthalmitis, — result- 
ing in  destruction  of  sight  and  ultimately  in  atrophy  of 
the  eyeball.  Serous  cyclitis  is  invariably  but  part  of  a 
general  uveitis,  which  condition  has  been  treated  of 
already  under  the  head  of  "serous  iritis." 

Intense  pain,  great  photophobia,  and,  especially, 
exquisite  sensitiveness  of  the  ciliary  region,  together 
with  marked  pericorneal  injection,  are  the  character- 
istic signs  of  plastic  and  of  purulent  cvclitis,  while  de- 
cided impairment  of  vision  is  usual  in  all  three  varieties, 
owing  to  the  cloudiness  of  the  vitreous  humor  which 
is  commonly  present. 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY.  269 

Treatment. — The  treatment  of  the  different  varieties 
of  cycHtis,  constitutional  as  well  as  local,  is  the  same  as 
in  the  corresponding  types  of  iritis,  mercury,  the  sali- 
cylates, and  potassium  iodid  being  indicated  in  the 
plastic  and  serous  forms,  and  quinin  in  generous  doses 
in  the  purulent  form,  while  atropin  in  strong  solution, 
dionin,  and  the  lotion  of  opium  are  called  for  in  the 
first  and  last  named  varieties. 

In  purulent  panophthalmitis  (see  Fig.  130)  prompt 
enucleation  of  the  eye,  which  saves  the  patient  from 
much  intense  suffering,  is  indicated.  The  risk  of 
cerebral  infection,  which  is  supposed  to  attend  the  per- 
formance of  the  operation  under  such  circumstances, 
is  probably  not  appreciably  greater  than  that  to  which 
the  patient  is  exposed  through  retention  of  the  suppurat- 
ing eye. 

Tumors  of  the  ciliary  body,  sarcomatous  growths 
more  especially,  are  not  so  rare  as  tumors  of  the  iris. 
Their  early  diagnosis,  which  is  of  the  utmost  importance, 
can  be  made  only  by  means  of  the  ophthalmoscope. 
When  they  are  of  malignant  character,  immediate 
enucleation  of  the  eye  is  demanded. 

Enucleation  of  the  Eyeball. — One  of  the  most 
definite  advances  in  ophthalmic  surgery  in  recent  years 
is  the  method,  now  universally  employed,  of  removing 
the  eyeball. 

The  modern  operation,  known  as  "enucleation"  .of 
the  eye,  was  devised  by  Bonnet,  in  1841.  The  operation 
of  "extirpation"  of  the  eye,  previously  practised,  a  prim- 
itive and  rude  procedure,  is  aptly  described  by  Fuchs  as 
"cutting  out  the  eyeball,  together  with  the  neighboring 
soft  parts,  in  a  not  very  different  way  from  that  in 
which  a  butcher  is  accustomed  to  do  it." 

The  chief  end  in  view,  and  a  most  important  one,  in 


2/0 


PREVALENT    DISEASES    OF    THE     EYE. 


the  operation  of  "enucleation"  is  the  preservation  of 
all  the  soft  parts  contained  in  the  orbit,  especially  the 
preservation  of  the  conjunctiva  and  the  muscles  con- 
cerned in  the  movements  of  the  globe,  so  that  only  the 
eyeball  itself,  freed  from  all  its  connections,  is  removed. 
This  results  in  securing  a  relatively  large  cavity,  lined 
by  mucous  membrane, — the  conjunctiva, — v^^ell  adapted 
to  receive  an  artificial  eye  of  the  requisite  size, 
and  a  movable  "stump,"  made  up  of  the  preserved 
muscles,  Tenon's  capsule,  and  the  fatty  tissue  of  the 


Fig.  109. — Bader's  scleral  fixation  forceps.  The  long,  sharp  teeth  bite 
into  the  sclera,  and  for  this  reason  they  are  invaluable  in  the  last  step  of 
enucleation  of  the  eye — the  division  of  the  optic  nerve. 


orbit,  which  not  only  gives  to  the  artificial  eye  a  much- 
desired  prominence,  but  enables  it,  at  least  in  consider- 
able measure,  to  follow  in  a  natural  way  the  excursions 
of  the  seeing  eye. 

The  several  steps  of  the  operation,  which,  except 
when  panophthalmitis  is  present  or  perforation  of  the 
globe  has  occurred,  for  example,  from  sloughing  of  the 
cornea,  is  a  very  simple  surgical  procedure,  are  well 
shown  in  the  accompanying  illustrations. 

A  general  anesthetic  and  careful  antiseptic  pre- 
cautions, of  course,  are  demanded.  The  instruments 
required     are    a    stop-speculum,    a    strabismus-hook. 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY. 


271 


Stout,  blunt-pointed,  scissors,  curved  on  the  flat,  a  pair — 
preferably  two  pairs — of  ordinary  fixation  forceps,  and 


Fig.  no. — Enucleation  of  eye.     The  first  step — the   circumcorneal  section 
of  the  conjunctiva — completed. 


Fig.  III.--  Ijuu  Kelt  ion  of  I  he  ryr.     Thi.'  .sen  )n(l  >u-]. — ili-.-.  i  tiwii  .  .f  the  recti 
muscles  from  their  scleral  attachment. 


the  scleral  fixation  forceps  of  Bader,  shown  in  the  cut — 
Fig.  109. 


2/2 


PRFVALENT    DISEASES    OF    THE     EYE. 


\\  itii  the  hxation  torceps  and  the  scissors  the  cir- 
cumcorneal  section  of  the  conjunctiva  (Fig.  no)  is 
easily  made — the  second  pair  of  fixation  forceps  often 
being  found  useful  to  rotate  the  eye  into  a  convenient 
position  for  seizing,  with  the  other  pair,  the  portion  of 
the  conjunctiva  we  wish  to  divide.  This  step  com- 
pleted, it  is  well,  with  the  scissors,  to  separate  the  con- 
junctiva, in  every  direction,  rather  widely  from  the  ball, 
so  that  the   second   step,   the   dissection   of  the   recti 


Fig.  112. — Enucleation  of  the  ere.     Dinsion  of  the  optic  nerve,  the  eyeball 
strongly  rotated  outward  by  means  of  Bader's  scleral  fixation  forceps. 

muscles  from  their  scleral  attachment  (Fig.  iii),  may 
be  more  readilv  accomplished. 

The  final  step — the  division  of  the  optic  nerve  (Fig. 
112) — is  not  so  easily  executed,  unless  provision  has  been 
made  for  exerting  traction  upon  the  eyeball,  so  as  to 
put  the  nerve  somewhat  upon  the  stretch.  There  are 
several  ways  of  accomplishing  this;  but,  to  my  mind, 
the  most  satisfactor\'  is  that  shown  in  Fig.  112 — the 
employment  of  the  scleral  fixation  forceps  of  Bader. 
These  forceps,  it  may  be  added,  are  especially  helpful 
when  it  is  desirable  to  sever  the  optic  nerve  at  a  con- 


DISEASES  OF  THE  IRIS  AND  CILIARY  BODY.  2/3 

siderable  distance  behind  the  scleral,  as  in  enucleation 
tor  malignant  intraocular  growths  or  for  sympathetic 
ophthalmitis. 

Considerable  hemorrhage  follows  the  division  of  the 
optic  nerve  and  the  ciliary  vessels  that  surround  it,  but, 
after  the  ball  has  been  completely  removed  from  the 
orbit  by  severing  the  attachments  of  the  oblique 
muscles  and  any  other  adherent  tissue,  this  is  easily 
controlled  by  firm  compression. 

The  after-treatment  is  very  simple,  and  recovery  from 
the  operation,  which  is  attended  by  little  or  no  shock, 
astonishingly  prompt.  Sterile  gauze  "sponges"  are 
applied  over  the  lids — somewhat  in  the  fashion  of  a 
graduated  compress — and  over  these  a  tight  bandage 
(Fig.  lo).  The  next  morning  these  compresses  are 
removed,  and  a  gauze  pad,  wet  with  a  saturated  solution 
of  boracic  acid,  is  applied  in  their  stead,  and  is  kept  wet 
by  repeated  applications  of  the  boracic  solution. 

As  soon  as  the  patient  has  recovered  sufficiently  from 
the  effects  of  the  anesthetic  to  w^ish  to  do  so,  he  is  per- 
mitted to  sit  up,  and  after  three  or  four  days  a  mon- 
ocular eye-shade  is  substituted  for  the  wet  pad  and  ban- 
dage. A  coUyrium  of  alum  and  boracic  acid  (alum.,  gr. 
iij;  acid,  boracic, gr.  xij;  aquae  destil.,  5j),to  be  dropped 
into  the  conjunctival  sac  three  times  a  day,  is  now 
prescribed,  and  the  patient,  if  he  desires,  may  leave  the 
hospital;  and,  at  the  expiration  of  a  month  from  the  date 
of  the  operation,  he  may  begin  to  wear  an  artificial  eye. 

It  is  the  practice  of  some  surgeons,  after  the  eye  is 
removed,  to  bring  together  the  edges  of  the  conjunctival 
wound  by  means  of  a  continuous  suture,  and  others, 
more  reprehensibly  still,  pack  the  orbit  with  sterile 
gauze.  Both  of  these  measures  are  as  uncalled  for  as 
they  are  objectionable;  and,  in  my  opinion,  the  same 


274  PREVALENT    DISEASES    OF    THE     EYE. 

criticism  applies,  because  of  the  unnecessary  traumatism 
involved,  to  the  "finicky"  procedures,  supposed  to  in- 
crease the  mobility  of  the  "stump,"  of  Suker,  Schmidt, 
Priestley  Smith,  and  others. 


CHAPTER  VIII. 
GLAUCOMA. 

Of  all  the  diseases  of  the  eye  there  is  none  that  it  is 
more  important  the  general  practitioner  should  be  able 
to  diagnosticate  than  glaucoma;  for  it  is  an  affection 
that  frequently  runs  so  rapid  a  course  that  failure  to 
recognize  it,  and  to  employ  promptly  the  proper  remedial 
measures,  may  result,  in  a  few  days,  in  irreparable 
blindness.  It  is  not  a  disease,  however,  which,  if  it 
can  be  avoided,  he  should  undertake  to  treat,  since  its 
proper  management  calls  for  the  skill  of  the  trained 
specialist.  Still,  as  its  onset  is  so  often  sudden,  he  is 
liable  to  be  called  upon  at  any  time,  especially  in  sections 
of  the  country  remote  from  large  centers  of  population, 
to  recognize  it,  to  point  out  its  serious  nature,  and,  at 
least,  to  suggest  temporary  measures  of  relief;  and  this 
much,  unquestionably,  he  should  be  capable  of  doing. 

As  is  well  known,  the  essential  feature  of  glaucoma 
is  an  increase  in  the  intraocular  tension — a  hardening 
of  the  eyeball.  This  increase  of  tension  may  be  slight 
and  continuous  or  it  may  be  excessive  and  intermittent 
in  character.  When  it  is  pronounced,  it  is  attended 
by  certain  characteristic  symptoms  which  are  not  diffi- 
cult of  recognition.  The  severity  of  an  attack  of  glau- 
coma and  the  amount  of  impairment  of  sight  depend 
largely  upon  the  degree  of  hardening  of  the  eyeball. 
The  impairment  of  vision  is  due  to  clouding  of  the 
media  of  the  eye,  to  the  pressure  to  which  the  optic 
nerve  is  subjected,  and  to  interference  with  the  blood- 


276  PREVALENT    DISEASES    OF    THE     EYE. 

supply  of  the  choroid  and  retina;  the  pain,  which  is 
often  excessive,  is  largely  the  direct  result  of  the 
increased  tension. 

There  are  two  markedly  different  types  of  glaucoma — 
inflammatory  glaucoma  and  simple  glaucoma.  These 
differ  radically  in  their  clinical  features,  in  the  treatment 
which  they  demand,  and,  probably,  not  less  radically 
in  their  etiology.  Besides  these  tw^o  varieties  of  "pri- 
mary" glaucoma,  certain  inflammatory  affections  of  the 
eye,  and  many  traumatic  lesions  as  well,  may  be  com- 
plicated by  an  increase  of  intraocular  tension,  to  which 
condition  the  name  "secondary"  glaucoma  is  applied. 

Although  secondary'  glaucoma  may  manifest  itself 
at  any  period  of  life,  primary  glaucoma,  of  either  variety, 
is  extremely  rare  under  thirty  years  of  age,  and  is  often- 
est  encountered  in  persons  who  have  reached,  or  have 
passed,  middle  life.  At  the  outset  primary  glaucoma  is 
commonly  monocular,  but,  sooner  or  later,  both  eyes 
are  almost  sure  to  become  involved.  In  the  rare  in- 
stances in  which  increased  intraocular  tension  is  met 
with  in  the  young  there  commonly  occurs  a  gradual  dis- 
tention of  the  sclerotic  coat  and  cornea,  so  that  the  whole 
eyeball  becomes  enlarged.  Under  such  circumstances 
the  depth  of  the  anterior  chamber  is  usually  consider- 
ably increased,  and  the  pupil  and  the  iris  itself  are  larger 
than  normal.  This  condition,  which  is  known  as  buph- 
thalmos,  is  not  infrequently  of  congenital  origin  (Fig. 
113).  The  enlargement  of  the  ball  finds  its  explanation 
in  the  fact  that  in  the  young  the  external  tunic  of  the 
eye  is  less  tough  than  in  the  adult,  and,  therefore,  yields 
to  the  continued  intraocular  pressure. 

Inflammatory  Glaucoma  (Glaucoma  with  Ex- 
acerbations).— It  is  this  variety  of  glaucoma,  with  its 
pronounced   inflammatory  symptoms,  that    not   infre- 


GLAUCOMA.  277 

quently  leads  to  rapid  destruction  of  sight,  though 
usually  this  is  not  the  outcome  of  a  first  attack;  for, 
as  the  subtitle  given  above  indicates,  the  disease  is  com- 
monly intermittent  in  character,  though  the  periods 
of  intermission  are  wholly  irregular. 

The  symptoms,  subjective  and  objective,  of  a  v^ell- 
marked  attack  of  inflammatory  glaucoma  are  very 
characteristic.  Severe  pain,  supraorbital  and  hemi- 
cranial  as  well  as  ocular,  accompanied  at  times  by 
nausea  and  vomiting;  more  or  less  complete  anesthesia 
of  the  cornea;*  pronounced  imoairment  of  vision,  and, 


Fig.  113. — Buphthalmos  (Haab). 

when  the  sight  is  not  too  profoundly  aff'ected,  the 
appearance  of  a  halo,  showing  the  rainbow  colors, 
about  the  flame  of  a  candle  or  a  lighted  match, 
are  the  chief  subjective  symptoms.  The  objective 
symptoms  (Plate  VII,  Fig.  2)  are  marked  peri- 
corneal and  general  conjunctival  injection;  steam- 
iness  of  the  cornea,  reminding  one  of  the  appearance 
produced  by  breathing  upon  a  plate  of  cold  glass; 
great  enlargement  of  the  pupil,  which  is  often  irregularly 

*  The   sensibility   of"  the   cornea    can    be   tested   conveniently   by 
touching  it  lightly  with  a  slender  spill  of  tissue  or  other  thin  paper. 


278  PREVALENT    DISEASES    OF    THE    EYE. 

oval  in  shape,  and  shows  httle  or  no  response  to  light; 
partial  or  complete  obliteration  of  the  anterior  chamber, 
due  to  the  lens  and  iris  being  pressed  forward  against 
the  cornea;  undue  pupillary  reflex,  suggestive  of  opacity 
of  the  lens,  and,  above  all,  increased  tension  of  the 
globe,  easily  detected  by  palpation  through  the  upper 
lid  while  the  eye  is  directed  downward  (see  Fig.  4). 
The  pain  and  injection  of  the  ball  are  not  characteristic, 
for  they  are  not  different  from  the  pain  and  injection 


Fig.  114. — Ophthalmoscopic  appearance  of  the  optic  disc  in  advanced  glau- 
coma   (Jaeger). 


encountered  in  iritis,  in  cyclitis,  and  in  severe  keratitis; 
but  in  these  conditions  we  have  a  contracted,  not  a 
dilated,  pupil,  an  anterior  chamber  of  normal  depth, 
no  anesthesia  of  the  cornea,  and  commonlv  no  increase 
of  intraocular  tension. 

Although  during  the  premonitory'  stage  of  glaucoma 
and  in  the  intervals  between  the  exacerbations  an 
ophthalmoscopic  examination  is  usually  required  to 
establish  the  diagnosis  (Fig.   114),  it  is  of  little  value 


GLAUCOMA.  279 

during  the  height  of  an  acute  attack;  for  then  the 
media  are  too  cloudy  to  permit  an  inspection  of  the 
fundus  of  the  eye,  and,  besides,  the  symptoms  are  so 
pathognomonic  that  the  information  which  the  oph- 
thalmoscope affords  under  other  circumstances  is  not 
missed. 

Before  the  onset  of  such  a  severe  attack  as  has  been 
described,  several,  perhaps  many,  less  marked  exacer- 
bations, in  all  probability,  will  have  occurred,  and  the 
true  character  of  these  is  not  so  easily  recognized  by 
the  physician  who  is  but  little  versed  in  the  management 
of  diseases  of  the  eye.  Among  the  earliest  of  the  pro- 
dromal symptoms  of  inflammatory  glaucoma  is  a  rapid 
failure  of  the  accommodative  power  of  the  eye,  necessi- 
tating, at  short  intervals,  an  increase  in  the  strength  of 
the  glasses  worn  in  near  vision.  Then  there  occurs, 
in  connection,  perhaps,  with  an  attack  of  indigestion 
or  after  prolonged  use  of  the  eyes,  a  transient  obscura- 
tion of  vision,  attended  by  slight  supraorbital  pain  and 
some  pericorneal  injection.  If  an  examination  of  the 
eye  is  made  at  this  time,  a  perceptible  hardening  of 
the  ball  will  be  detected,  and  a  test  with  the  candle 
flame  will  show  the  rainbow-colored  halo.  The  oph- 
thalmoscope would  show,  besides,  a  jerky  pulse  in  the 
central  retinal  veins  or,  perhaps,  a  slight  arterial  pulse. 
After  a  night's  rest  the  eye  will  have  returned  nearly 
or  quite  to  its  normal  condition,  and  some  weeks  may 
elapse  before  a  similar,  but  probably  more  pronounced, 
attack  occurs.  The  recovery  from  this  next  exacerba- 
tion will  be  less  prompt,  and  after  several  such  attacks 
a  perimetric  test  will  reveal  a  perceptible  contraction 
of  the  nasal  half  of  the  field  of  vision,  and  the  ophthal- 
moscope will  show  a  depression  of  the  optic  disc — the 
beginning  of  a  glaucomatous  "cup"  (Fig.  115).     After 


280  PREVALENT    DISEASES    OF    THE    EYE. 

another  interval  of  uncertain  length,  and  again  pre- 
cipitated by  some  exciting  cause,  such  as  overstrain  of 
the  eyes,  a  spell  of  crying,  etc.,  there  will  occur  a  well- 
marked  attack  of  glaucoma,  and  after  this  has  subsided, 
if  it  does  subside  without  radical  treatment,  vision  will 
remain  more  or  less  seriously  impaired. 

Such  is  the  usual  history  of  a  case  of  inflammatory 
glaucoma,  until,  in  the  course  of  time,  a  much  more 
severe  attack  occurs,  and  sight  is  permanently  lost. 
But  even  when    this  has    happened    the   disease    has 


P:-- 


Fig.   115. — Section  of  optic  nerve-head  showing  deep  glaucomatous  exca- 
vation (Lippincott). 

not  run  its  course,  and  much  suflFering  is  still  in  store 
for  the  unfortunate  individual;  for  many  acute  exacer- 
bations, caused  by  a  temporary  increase  in  the  tension 
of  the  eye,  and  accompanied  by  intense  pain,  are  liable 
to  occur,  until  finally,  the  lens  having  already  become 
cataractous,  the  eyeball  undergoes  partial  atrophy, 
becomes  abnormally  soft,  and  remains  comparatively 
quiescent.  It  is  still,  however,  a  source  of  danger, 
since  in  not  a  few  instances  such  a  blind  and  atrophied 


GLAUCOMA.  281 

eye  has  been  known  to  induce  sympathetic  ophthal- 
mitis in  the  fellow-eye. 

From  the  foregoing  description  it  is  evident  that  there 
is  Httle  excuse  for  mistaking  inflammatory  glaucoma 
for  iritis,  cyclitis,  or  keratitis,  and  still  less  for  conjuncti- 
vitis. For  confounding  it  with  cataract,  as  the  experi- 
ence of  every  ophthalmic  surgeon  shows  is  done  not 
very  rarely,  there  is,  of  course,  no  excuse  whatever, 
since  cataract,  unless  compHcated  by  other  disease  of 
the  eye,  is  never  attended  by  pain,  injection  of  the  ball, 
or  other  evidences  of  inflammation.  To  mistake  it  for 
a  severe  attack  of  facial  neuralgia  is  less  reprehensible; 
but  such  an  error  can  be  made  only  when  one  neglects 
to  examine  the  eye,  and  so  fails  to  note  the  steamy  cor- 
nea, the  enlarged  pupil,  the  shallow  anterior  chamber, 
and  the  increased  tension  of  the  globe. 

Let  the  general  practitioner  but  once  realize  that 
glaucoma  is  to  be  suspected,  and  to  be  carefully  searched 
for,  w^henever  a  painful  inflammation  of  the  eye 
attended  by  obscuration  of  sight  is  encountered  in  an 
individual  who  has  reached,  or  has  passed,  middle 
life,  and  errors  in  diagnosis  such  as  have  been 
mentioned  will  become  very  rare  indeed,  and  both 
his  own  reputation  and  the  welfare  of  his  patients  will 
be  great  gainers  thereby. 

Much  careful  research  has  been  undertaken  with  the 
view  of  throwing  light  upon  the  etiology  of  inflammatory 
glaucoma,  but  our  knowledge  upon  the  subject  is  as 
yet  far  from  exact.  In  order  to  a  clear  comprehension 
of  the  matter,  it  must  be  borne  in  mind  that  there  is  a 
constant  and  very  considerable  flow  of  lymph  through 
the  chambers  of  the  eye.  This  lymph-stream,  which 
is  necessary  to  maintain  the  non-vascular  media  of  the 
eye — the  vitreous  humor,  the  crystalline  lens,  and  the 


282  PREVALENT    DISEASES    OF    THE     EYE, 

cornea — in  a  normal  condition,  is  supplied  in  large  part 
by  the  very  vascular  uveal  coat,  composed  of  the  choroid, 
the  ciliary  body,  and  the  iris.  In  the  main  the  direction 
of  the  current  is  forward — from  the  vitreous  chamber, 
through  the  circumlental  space  and  through  the  pupil, 
to  the  anterior  chamber,  where  it  accumulates  in  con- 
siderable quantity  as  the  aqueous  humor  (Fig.  116). 
Having  performed  its  office  the  lymph  must  escape  from 
the  eye,  and  this  is  provided  for  by  the  existence  of 
certain  drainage  channels,  the  chief  one  being  at  the 
periphery  of  the  anterior  chamber,  where  there  are 
numerous  "lymph-spaces"  which  connect  with  the 
canal    of    Schlemm.       In     addition,    there     are    the 


Fig.  116. — Direction  of  intraocular  lymph-stream  (Jackson). 

lymphatic  vessels  which  accompany  the  venae  vorticosae 
in  their  passage  through  the  sclera,  and  the  lymph- 
spaces  which  surround  the  optic  nerve. 

In  order  that  the  intraocular  tension  may  be  main- 
tained at  its  normal  standard,  it  is  evident  that  an  equi- 
librium must  exist  between  the  inflow  and  the  outflow 
of  this  lymph-stream.  If  the  inflow  does  not  equal 
the  outflow,  the  intraocular  tension  will  be  reduced,  the 
eye  will  be  abnormally  soft;  on  the  other  hand,  if  the 
conditions  are  reversed  the  tension  will  be  increased, 
the  eye  will  be  abnormally  hard.  A  hardening  of  the 
eyeball,  in  other  words,  a  glaucomatous  condition,  it  will 
be  seen,  may  be  brought  about  in  either  of  two  ways 


GLAUCOMA. 


2^3 


— by  an  increase  in  the  inflow  of  lymph  beyond  the 
normal  capacity  of  the  drainage  apparatus,  or  by  an  ob- 
struction or  clogging  of  the  outflow  channels  whereby  the 
escape  of  lymph  is  impeded.  It  is  probable  that  both 
of  these  conditions — an  increase  in  the  inflow  and  an 
obstruction  of  the  outflow  of  lymph — are  concerned  in 
the  causation  of  many  cases  of  inflammatory  glaucoma, 


Fig.  117. — Section  of  iris  and  ciliary  body  in  recent  inflammatory  glau- 
coma, showing  obliteration  of  the  filtration  angle.  Magnified  g  X  r  (Fuchs). 
The  ciliary  process,  c,  is  so  greatly  swollen  that  it  pushes  the  root  of  the  iris 
forward  and  presses  it  against  the  sclera,  5,  and  the  cornea,  C.  The  sinus  of 
the  anterior  chamber,  which  should  lie  somewhat  behind  Schlemm's  canal,  s, 
is  thus  closed.  The  ciliary  muscle  shows  the  pronounced  development  of 
the  circular  muscular  fibers  (Miiller's  portion),  characteristic  of  the  hyper- 
metropic eye. 


though  the  inclination  at  the  present  day  is  to  regard 
the  latter  condition  as  the  more  potent  factor. 

It  would  be  out  of  place  to  enter  into  a  discussion  of 
the  many  theories  which  have  been  advanced  to  ex- 
plain the  production  of  glaucoma.  The  view  most 
widely  accepted  is  that  the  hardening  of  the  eyeball  is 
due  to  obstruction  of  the  lymph-spaces  about  the 
periphery  of  the  anterior  chamber,  the  so-called  filtra- 
tion angle  (Figs.  117  and  118).  Another  view  attaches 
more    importance   to    compression    of  the  lymphatic 


284 


PREVALENT    DISEASES    OF    THE     EYE, 


vessels  which  pass  through  the  sclera  with  the  venae 
vorticosae;  another,  to  narrowing  of  the  circumlental 
space,  which  has  a  normal  width  of  but  half  a  milli- 
meter, whereby  the  flow  of  lymph  from  the  vitreous 
chamber  to  the  aqueous  chamber  is  obstructed;  while 


Fig.  118. — Section  of  iris  and  ciliary  body  in  advanced  inflammatory 
glaucoma,  showing  atrophy  of  the  iris  and  adhesion  of  its  periphery  to  the 
sclera  and  cornea,  also  pronounced  atrophy  of  the  ciliary  body.  Magnified  9X1 
(Fuchs).  The  dotted  line  gives  the  outline  of  the  iris,  I^,  and  the  ciliary  body, 
Cj,  in  the  normal  condition.  The  root  of  the  iris  is  adherent  to  the  sclera,  Sr 
and  the  cornea,  C,  wherever  it  has  been  pressed  against  them  by  the  ciliary 
body.  The  attachment  of  the  iris  is  hence  displaced  forward  and  lies  in 
front  of  Schlemm's  canal,  5.  So,  too,  the  sinus  of  the  anterior  chamber  is 
displaced  from  b  to  a.  Wherever  the  iris  has  become  adherent,  it  has  been 
thinned  through  atrophy,  so  that  in  places — h,  for  example — it  consists  of 
scarcely  anything  more  than  the  pigment  layer.  Even  the  free  portion  of  the 
iris,  /,  appears,  in  consequence  of  its  atrophy,  narrower  than  the  normal  iris,  7j. 
Over  the  pupillary  border,  e,  the  retinal  layer  of  pigment  turns  forward 
farther  than  usual,  and  the  sphincter  pupillae,  p,  also  shares  to  some  extent 
in  this  eversion.  The  ciliary  body,  owing  to  its  having  become  atrophic, 
has  again  separated  from  the  iris,  and  in  fact  more  so  than  in  the  normal  con- 
dition, so  that  it  is  now  removed  from  the  iris  by  a  broad  interval.  The 
atrophy  affects  both  the  ciliary  muscle,  m,  and  the  ciliary  process,  c. 


still  another  maintains  that  under  certain  circumstances 
there  is  an  alteration  in  the  consistency  of  the  lymph 
— a  serosity- — which  interferes  with  its  escape  through 
the  drainage  channels. 

Those,  of  whom  I  am  one,  who  consider  that  an  in- 


GLAUCOMA.  285 

crease  in  the  lymph-stream,  a  hypersecretion  of  lymph, 
is  not  infrequently  a  factor  in  the  production  of  glauco- 
matous tension,  believe  that  this  increase  is  often 
brought  about,  through  the  resulting  hyperemia  of  the 
uveal  coat,  by  the  strain  of  accommodation  due  to  errors 
of  refraction.  It  is  a  v^ell-known  fact  that  hypermetro- 
pic eyes  are  especially  disposed  to  develop  glaucoma, 
though  this  has  been  explained  upon  the  ground  that 
in  such  eyes  the  circumlental  space  is  narrower  than 
in  the  emmetropic  or  myopic  eye.  The  frequency  with 
which  astigmatism,  and  especially  astigmatism  "against 
the  rule," — a  refractive  error  which  gives  rise  to  an 
exceptional  amount  of  accommodative  strain, — is  found 
in  association  with  glaucoma,  attracted  my  attention 
many  years  ago,  and  was  made  the  subject  of  a  com- 
munication to  the  American  Ophthalmological  So- 
ciety.* In  this  connection  the  fact,  to  which  reference 
has  been  made,  that  attacks  of  glaucoma  are  frequently 
precipitated  by  prolonged  use  of  the  eyes  in  near  work — 
reading,  writing,  etc. — is  significant. 

Among  the  general  conditions  which  are  regarded 
as  favoring  the  development  of  glaucoma  may  be  men- 
tioned, rheumatism,  gout,  angiosclerosis,  and  the  meno- 
pause. It  should  be  mentioned  also  that  the  employ- 
ment of  a  mydriatic  in  persons  predisposed  to  glaucoma 
has  been  known  frequently  to  precipitate  an  attack  of 
the  disease,  the  explanation  being  that  when  the  pupil 
is  widely  dilated  the  iris  is  crowded  into  the  periphery 
of  the  anterior  chamber  in  such  a  manner  as  to  obstruct 
the  filtration  angle.  For  this  reason,  the  indiscrimi- 
nate use  of  mydriatics  in  persons  beyond  middle  life 
is  regarded  as  reprehensible. 

Writers  commonly  subdivide  inflammatory  glaucoma 
*  Transactions  American  Ophthalmological  Soc,  1888. 


286 


PREVALENT    DISEASES    OF    THE     EYE. 


into  three  varieties — acute,  subacute,  and  chronic. 
These  subdivisions  are  more  or  less  artificial,  though 
they  serve  to  emphasize  the  fact  that  in  some  instances 
the  disease  runs  a  rapid  course,  the  exacerbations  are  of 
frequent  occurrence  and  severe  in  character,  and  vision 
is  soon  destroyed;  while  in  others  the  attacks  occur 
at  long  intervals,  and  are  comparatively  mild,  so  that 
a  much  longer  time  elapses  before  sight  is  seriously 
impaired  (Fig.  119).  In  what  is  known  as  "fulmi- 
nating glaucoma"  all  the  symptoms  are  greatly  inten- 
sified, and  sight  may  be  destroyed  in  the  brief  period  of 


Fig.  119. — Chronic  inflammatory  glaucoma,  advanced  stage  (Ramsay). 


forty-eight  or  even  twenty-four  hours.  One  of  the  most 
unpromising  types  of  inflammatory  glaucoma  is  that 
which  is  attended  by  recurrent  intraocular  hemor- 
rhages— from  the  retinal  vessels  chiefly — and  which, 
therefore,  is  known  as  "hemorrhagic  glaucoma." 
"Malignant  glaucoma"  is  a  term  chiefly  employed  by 
ophthalmic  surgeons,  it  would  seem,  to  characterize 
cases  upon  which  they  have  operated  unsuccessfully. 
The  impairment  of  vision  in  advanced  glaucoma 
frequently  exhibits  a  characteristic  which  is  very  strik- 
ing. One  of  the  early  symptoms  of  the  disease,  as  has 
been  pointed  out,  is  a  narrowing  of  the  nasal  half  of  the 


GLAUCOMA.  287 

visual  field.  In  time  this  contraction  of  the  field  be- 
comes general,  and  slowly  progresses  toward  the  point 
of  fixation.  As  a  result  of  this,  in  extreme  cases,  vision 
is  lost  everywhere  except  at  the  fovea.  Under  such  cir- 
cumstances the  sight  is  much  like  that  which  one  obtains 
in  looking  through  a  long,  narrow  tube,  a  gun-barrel, 
for  example.  Persons  in  this  condition,  though  on  the 
street  they  may  seem  to  be  quite  blind,  and  have  to  be 
led  about,  often  are  able  to  distinguish  comparatively 
small  test-letters  at  twenty  feet,  when,  after  considerable 
difficulty,  they  have  succeeded  in  "finding"  them,  and 
fixing  their  gaze  directly  upon  them. 

Treatment. — The  sovereign  remedy  in  the  treatment 
of  inflammatory  glaucoma  is  the  operation  of  iridectomy, 
and  the  sooner  this  is  performed  the  more  favorable 
is  the  prognosis.  For  this  reason  it  is  inadmissible 
for  the  general  practitioner  to  lose  valuable  time  in 
endeavoring  to  combat  the  disease  by  less  efficient 
measures.  On  the  contrary,  it  is  incumbent  upon  him 
as  soon  as  he  has  recognized  its  true  character  to  refer 
the  case,  with  the  least  possible  delay,  to  the  ophthalmic 
surgeon.  To  undertake  the  performance  of  the  opera- 
tion himself  would  be  justifiable  only  if  it  were  imprac- 
ticable for  him  to  do  otherwise;  for  there  are  few  opera- 
tions in  ophthalmic  surgery  which  call  more  distinctly 
for  especial  skill  and  training  than  an  iridectomy  for 
glaucoma,  particularly  if  it  has  to  be  done,  as  is  often 
the  case,  during  an  acute  exacerbation  ot  the  disease. 
The  most  favorable  opportunity  for  the  performance 
of  the  iridectomy  is  between  the  exacerbations;  but, 
if  the  attack  is  a  severe  one,  it  is  not  permissible  to 
defer  the  operation  until  the  eye  has  become  quiet, 
for  before  this  happens  serious  and  permanent  damage 
may  have  been  done  to  the  sight. 


256  PREVALENT    DISEASES    OF    THE     EYE. 

There  are,  however,  certain  measures  which  the 
physician  under  whose  observation  the  case  first  comes 
should  employ  without  delay,  and  which,  possibly, 
may  cut  short  the  attack,  or,  if  they  do  not  accomplish 
this,  may,  at  least,  lessen  its  severity,  and  so  place  the 
eye  in  a  more  favorable  condition  for  operation.  In 
the  first  place,  he  should  prescribe  a  solution  of  eserin 
for  application  to  the  eye.  The  good  which  eserin 
accomplishes  in  glaucoma  is  due  to  its  mechanical  eflTect 
upon  the  iris.  As  atropin  tends  to  induce  glaucoma 
by  dilating  the  pupil,  and  thereby  crowding  the  iris  into 
the  periphery  of  the  anterior  chamber,  eserin  tends  to 
reduce  increased  tension  by  contracting  the  pupil,  and 
drawing  the  iris  away  from  the  filtration  angle.  To  ob- 
tain the  desired  effect,  therefore,  eserin  must  be  used 
in  such  strength  as  to  cause  decided  contraction  of  the 
pupil. 

During  an  acute  attack  of  glaucoma  it  is  usually 
difficult,  and  not  infrequently  impossible,  to  induce  the 
pupil  to  contract  even  by  the  most  liberal  use  of  eserin. 
Under  such  circumstances,  therefore,  it  should  be 
prescribed  in  strong  solution — in  a  solution  of  the 
strength  of  four  grains  to  the  ounce  (eserin  sulphate,  gr. 
ii;  aquae  destil.,  5ss) — and  this  should  be  applied  from 
three  to  four  times  in  twenty-four  hours.  After  the 
subsidence  of  the  attack,  however,  a  much  weaker 
solution — perhaps  only  half  a  grain,  or  even  a  quarter 
of  a  grain,  to  the  ounce — suffices  usually  to  maintain 
the  pupil  in  a  state  of  contraction;  therefore  such  a  weak 
solution,  the  weakest  solution,  in  fact,  that  will  produce 
the  desired  effect  upon  the  pupil,  should  be  employed 
under  such  circumstances,  and  this  will  probably  not 
have  to  be  used  more  than  two  or  three  times  a  day. 
Another  useful  local   remedy  is  the  lotion  of  opium, 


GLAUCOMA.  289 

which  is  apt  to  be  more  grateful  if  appHed  warm.  Di- 
onin,  in  conjunction  with  eserin,  has  also  proved  useful 
in  the  acute  exacerbations  of  inflammatory  glaucoma, 
through  its  action  as  a  lymphagogue  and  an  analgesic. 

The  constitutional  measures  called  for  are  the  ad- 
ministration, without  delay,  of  an  energetic  calomel 
purge  (calomel,  gr.  iij-iv;  pulv.  scammonii  virg.,  gr. 
ij;  pulv.  rad.  rhei,  gr.  vj),  and,  when  this  has  had  its 
effect,  the  further  administration,  in  liberal  doses, — ten 
grains  every  two  hours — of  sodium  or  lithium  salicylate. 
Opium  in  some  form  may  also  be  given  to  lessen  the 
pain. 

As  has  been  stated,  the  prompt  employment  of  these 
measures  may  control  even  a  well-marked  attack  of  glau- 
coma; but  should  so  fortunate  a  result  ensue  it  would 
not  warrant  unnecessary  delay  in  resorting  to  operation, 
for  the  outcome  of  the  next  attack  might  be  far  different. 

As  to  what  may  be  promised  from  a  well-executed 
and  promptly  performed  iridectomy,  it  may  be  said  that 
the  result  usually  is  extremely  satisfactory,  and  this 
applies  not  only  to  the  immediate  but  to  the  per- 
manent result.  If  the  operation  is  performed  before 
serious  damage  has  been  done  to  the  optic  nerve 
and  retina,  the  restoration  of  practicably  normal  vision 
may  be  anticipated,  as  well  as  complete  relief  from 
subsequent  suffering.  But  even  if  so  favorable  an  out- 
come is  not  to  be  expected,  still  the  operation  should 
be  done  with  as  little  delay  as  possible;  indeed,  it  is 
indicated  for  the  relief  of  suffering,  though  there  may 
be  no  hope  whatever  of  restoring  vision.  Exception- 
ally, in  the  cases  of  so-called  malignant  glaucoma, 
iridectomy  fails  entirely  to  arrest  the  progress  of  the  dis- 
ease, and  sight  is  destroyed  in  a  very  brief  time.  When 
this  has  happened,  and  the  inflammation  and  pain  per- 
19 


290  PREVALENT    DISEASES    OF    THE     EYE. 

sist,  the  eye  should  be  enucleated,  as  this  will  put  an  end 
to  all  suffering.  Fortunately  cases  of  this  character  are 
extremely  rare. 

As  inflammatory  glaucoma  is  so  invariable  a  binoc- 
ular aff"ection,  every  possible  precaution  should  be 
taken  w^hen  the  disease  has  manifested  itself  in  one  eye 
to  prevent  its  occurrence  in  the  lellow-eye.  These 
precautions  should  include,  besides  care  in  the  use  of 
the  eyes,  regulation  of  the  bov^-els,  and  temperance  in 
eating  and  drinking,  the  careful  correction  of  any  re- 
fractive error  found  to  be  present,  and  the  use  of  eserin 
upon  the  appearance  of  the  first  premonitory  symptoms 
of  the  disease. 

Experience  has  convinced  me  that  not  only  in  dealing 
with  the  second  eye  but,  if  the  case  can  be  seen  early 
in  the  prodromal  stage,  in  controlling  the  development 
of  the  disease  in  the  primarily  affected  eye,  much  is  to 
be  hoped  for  from  the  wearing  of  accurately  adjusted 
glasses — of  glasses  which  exactly  correct  any  refractive 
or  muscular  anomaly  that  may  be  present,  and  thus 
do  away  with  all  strain  in  both  distant  and  near  vision. 

The  conviction  forced  upon  me  years  ago,  that  com- 
plicated errors  of  refraction  often  play  an  important 
part  in  the  causation  of  glaucoma,  has  grown  stronger 
with  more  extended  observation,  and  I  venture  the  opin- 
ion that  if  in  the  ir.cipient  stage  of  every  case  of  glau- 
coma refractive  and  muscular  anomalies  were  carefully 
searched  for,  and  as  carefully  corrected,  there  would  be  [ 
an  appreciable  diminution  in  the  number  of  cases 
demanding  operation.  To  those  who  have  had  con- 
siderable experience  with  refractive  anomalies,  and  know 
how  often  accommodative  strain  gives  rise  not  only  to 
marked  hyperemia  but  to  a  low  grade  of  inflanmiation 
of  the    inner  tunics  of   the  eye,  this    statem.ent    will, 


GLAUCOMA.  291 

perhaps,  not  seem  extravagant.  I  Vvould,  therefore, 
strongly  insist  upon  the  importance  of  a  thorough  exam- 
ination of  the  refraction  in  every  case  of  incipient  glau- 
coma, and  especially  upon  its  importance  with  reference 
to  the  uninvolved  eye,  when  the  disease  has  manifested 
itself  in  one  eye  only. 

Simple  Glaucoma  (Chronic  Non-inflammatory 
Glaucoma). — This  disease,  which  is  characterized  by 
a  slight  and  persistent  increase  of  the  intraocular  ten- 
sion, is  attended  by  none  of  the  signs  of  active  inflam- 
mation observed  in  inflammatory  glaucoma.  There  , 
is  no  pain,  no  injection,  no  clouding  of  the  media,  1 
if  we  except  a  very  slight  diminution  in  some  instances 
of  the  corneal  transparency,  and  little  or  no  shallowing 
of  the  anterior  chamber,  and  the  pupil,  though  sluggish 
in  its  response  to  light,  is  but  slightly  enlarged.  The 
increase  of  tension  is  often  so  inconsiderable  as  to  be 
difiicult  of  detection  and,  though  it  varies  somew^hat 
in  degree  from  time  to  time,  it  is  never  very  pronounced. 

The  first  symptom  to  direct  the  patient's  attention 
to  the  condition  of  his  eyes  is  failure  of  vision.  This, 
which  at  first  is  scarcely  perceptible,  progresses  slowly, 
until  after  the  lapse  of  several  years  sight  may  be  entirely 
lost.  As  in  inflammatory  glaucoma,  there  is  early  in 
the  disease  a  contraction  of  the  visual  field,  the  nasal 
half  of  the  field  being  first  involved.  Like  inflammatory 
glaucoma,  too,  it  is  an  affection  of  advanced  life,  being 
seldom  observed  in  persons  under  forty-five  or  fifty 
years  of  age,  and  it  almost  invariably  attacks  both  eyes. 
As  to  its  etiology  little  is  known.  Gout,  rheumatism, 
and  angiosclerosis  are  looked  upon  as  conditions  pre- 
disposing to  its  development. 

An  ophthalmoscopic  examination  and  a  perimetric 
test  of  the  field  of  vision  are  necessary^  to  a  diagnosis  of 


292  PREVALENT    DISEASES    OF    THE     EYE, 

simple  glaucoma,  and  even  with  these  aids  it  is  not 
always  easy  to  distinguish  it  from  simple  progressive 
atrophy  of  the  optic  nerve.  In  each  of  these  conditions 
there  is  contraction  of  the  field  of  vision  and  cupping  of 
the  optic  disc;  but  in  progressive  atrophy  of  the  nerve 
the  contraction  of  the  field  does  not  begin  in  the  nasal 
half,  as  in  simple  glaucoma,  and  the  cupping  of  the 
disc  is  less  marked  in  proportion  to  the  loss  of  vision; 
there  is,  moreover,  in  simple  glaucoma  a  halo-like  ring 
about  the  disc — a  ring  of  partial  choroidal  atrophy — 
which  is  not  present  in  progressive  atrophy  of  the  nerve. 

Treatme77t. — Whatever  plan  of  treatment  may  be 
employed  the  prognosis  is  far  from  favorable.  Iridec- 
tomy is  by  no  means  the  effective  remedy  in  simple  glau- 
coma that  it  is  in  the  inflammatory  type  of  the  disease. 
Indeed,  its  results  are  so  uncertain  that  many  experi- 
enced ophthalmic  surgeons  regard  it  as  a  measure  to 
be  resorted  to  only  when  all  other  remedies  have  been 
tried,  and  found  of  no  avail.  Failure  to  arrest  the 
progress  of  the  disease  is  not  the  only  count  that  can 
be  brought  against  it;  for  not  rarely  it  is  followed  by  a 
marked  change  for  the  worse  in  the  state  of  the  eye, 
the  tension  being  decidedly  increased,  and  a  condition 
more  like  inflammatory  glaucoma  being  precipitated, 
which  may  soon  lead  to  complete  destruction  of  sight. 
Still,  as  the  operation  in  some  instances  does  unques- 
tionably control  the  disease,  it  is  a  warrantable  pro- 
cedure when  other  remedies  have  proved  ineffectual, 
since,  under  such  circumstances,  it  offers  the  only  hope 
of  preventing  certain  blindness. 

Some  excellent  authorities,  prominent  among  them 
being  Dr.  Charles  Stedman  Bull,  of  New  York,  it 
should  be  stated,  look  upon  iridectomy  in  simple  glau- 
coma with  more  favor,  and  believe  that  it  should  be 


GLAUCOMA. 


293 


performed  as  early  in  the  disease  as  possible,  as  soon, 
indeed,  as  the  diagnosis  can  be  established  with  cer- 
tainty. Sympathectomy,  or  excision  of  the  superior 
ganglion  of  the  cervical  sympathetic  nerve,  is  another 
operative  procedure  which  has  been  recommended 
in  simple  glaucoma;  but  the  claims  made  at  first  as  to  its 
utility  have  not  been  sustained  by  wider  experience  with 
the  method. 

The  remedial  measures,  other  than  operative,  are 
the  use  of  eserin  in  such  strength  as  to  maintain  the 
pupil  in  a  state  of  moderate  contraction — usually  an 
eighth-of-a-grain-,  or  a  quarter-of-a-grain-to-the-ounce 
solution,  applied  twice  a  day,  will  accomplish  this; 
the  correction  of  any  error  of  refraction  that  may  be 
present;  moderation  in  the  use  of  the  eyes;  regulation 
of  the  bowels,  and  attention  to  the  condition  of  the 
system,  with  special  reference  to  the  possible  depend- 
ence of  the  disease  upon  a  rheumatic  or  gouty  diathesis. 
Potassium  iodid  in  moderate  doses  is  especially  worthy 
of  trial. 

Secondary  Glaucoma. — Increased  intraocular  ten- 
sion consequent  upon  an  injury  or  upon  pre-existent 
disease  of  the  eye  is  denominated  secondary  glau- 
coma. The  diseases  and  injuries  most  apt  to  lead 
to  this  condition  are  those  which  involve  the  cornea, 
iris,  lens,  or  ciliary  body.  Among  these  may  be  men- 
tioned, prominently,  perforating  ulcers  and  penetrating 
wounds  of  the  cornea,  complicated  by  the  formation 
of  anterior  synechia;  neglected  iritis,  leading  to  exten- 
sive adhesion  of  the  iris  to  the  lens  capsule,  and  especially 
those  cases  in  which  there  is  complete  adhesion  of 
the  pupillary  margin  to  the  capsule,  since  in  these  the 
flow  of  lymph  from  the  vitreous  to  the  aqueous  chamber 
is  prevented;    penetrating  wounds  of  the  ciliary  region, 


294  PREVALENT    DISEASES    OF    THE     EYE. 

followed  by  prolapse  of  the  ciliary  body;  and  injuries 
causing  dislocation  of  the  lens,  or  rupture  of  its  capsule 
and  the  consequent  formation  of  a  traumatic  cataract. 
Intraocular  growths,  especially  those  of  malignant  type, 
such  as  sarcoma  of  the  ciliary  body  or  choroid  coat, 
are  also  usually  attended  by  increase  ot  intraocular 
tension,  and,  as  has  already  been  stated,  this  may  hap- 
pen also  in  the  course  of  serous  iritis,  or  uveitis. 

The  symptoms  and  the  consequences  to  sight,  if 
the  increase  of  tension  is  marked  and  is  not  soon  con- 
trolled, are  the  same  as  in  the  inflammatory  type  of 
primary  glaucoma. 

Treatment. — This  will  vary  with  the  conditions  that 
have  induced  the  glaucomatous  tension.  Iridectomy 
is  indicated  if  there  is  anterior  or  posterior  synechia; 
abscission,  combined,  perhaps,  with  iridectomy,  if 
there  is  prolapse  of  the  iris  or  ciliary  body;  extraction 
of  the  lens  if  there  is  a  swollen  traumatic  cataract;  and 
prompt  enucleation  of  the  eye  if  the  existence  of  a 
malignant  intraocular  grow^th  can  be  established. 
Sodium  salic^^late  and  in  some  instances  mercur}^  are 
very  useful,  and,  especially  when  there  is  a  traumatic 
cataract,  potassium  iodid,  which  promotes  the  absorp- 
tion of  the  extruded  lens  substance.  Eserin  is  seldom 
indicated,  though  in  uveitis,  if  the  pupil  is  much  en- 
larged, it  may  be  used  with  caution.  If  employed  too 
freely  in  this  condition  it  may  aggravate  the  iritis,  and 
cause  the  formation  of  posterior  synechiae.  The  lotion 
of  opium,  applied  hot  or  cold  as  may  be  more  grateful 
to  the  patient,  is  often  of  benefit. 


CHAPTER  IX. 

DISEASES  OF  THE  CRYSTALLINE  LENS  AND 
VITREOUS  HUMOR. 

DISEASES  OF  THE  CRYSTALLINE  LENS. 

Enclosed  in  its  capsule,  and  held  in  place  by  its  suspen- 
sory ligament,  the  zonule  of  Zinn,  the  crystalline  lens 
lies  in  the  hyaloid  fossa,  a  saucer-like  depression  on  the 
anterior  surface  of  the  vitreous  humor.  The  capsule 
of  the  lens  is  a  highly  elastic,  homogeneous  membrane, 
capable  of  offering  great  resistance  to  chemical  agents, 
heat  (boiling  water),  and  putrefactive  influences. 
That  part  of  it  which  covers  the  front  of  the  lens,  and 
which  is  known  as  the  anterior  capsule,  is  considerably 
thicker  than  the  posterior  half,  which  lies  in  contact 
with  the  vitreous  humor.  The  central  portion  of  the  iris, 
the  zone  of  contact  varying  in  width  with  the  size  of  the 
pupil,  rests  upon  the  anterior  capsule.  Being  .  an 
epithelial  structure,  like  the  hair  and  nails,  the  lens 
continues  to  grow  throughout  life,  and  is  considerably 
larger  and  heavier  in  old  age  than  it  is  in  youth.  Its 
growth  is  provided  for  by  the  presence  beneath  the  an- 
terior capsule  of  a  layer  of  cubical  epithelial  cells, 
which  become  elongated  and  converted  into  the  six- 
sided  prismatic  fibers  of  which  the  lens  is  composed 
(Fig.  120). 

In  early  life,  up  to  about  the  thirtieth  year,  the  whole 
lens  is  soft,  the  central  and  cortical  portions  being  of 
the  same  consistency.  After  this  period,  through  a 
process  of  sclerosis  affecting  the  oldest  fibers,  which 

295 


296 


PREVALENT    DISEASES    OF    THE    EYE. 


now  constitute  only  the  central  portion  of  the  lens, 
there  is  formed  a  relatively  hard  nucleus.  At  first  this 
central  nucleus  is  small  in  proportion  to  the  size  of  the 
whole  lens,  and  is  but  slightly  harder  than  the  com- 
paratively thick  layer  of  newly  formed  lens  fibers  which 
surrounds  it.     With  advancing  age,  however,  it  grows 


Fig.  1 20. — Meridional  section  through  human  cn-stalline  lens  (Babuchin) : 
A,  Anterior,  B,  posterior  surface;  C,  C,  equatorial  region;  i,  i',  anterior 
and  posterior  capsule;  2,  epithelium  beneath  anterior  lens-capsule;  3,  lens 
substance  composed  of  fibers;  4,  transition  zone  where  cells  of  anterior 
epithelium  are  converted  into  lens-fibers;  5,  nucleus. 


larger  and  increases  in  hardness,  so  that  ultimately  it 
constitutes  the  major  part  of  the  lens,  the  soft  cortical 
laver  which  encloses  it  being  now  inconsiderable  in 
thickness.  Besides  this  change  in  its  structure,  which 
is  attended  by  a  diminution  of  its  elasticity  and  an 
appreciable  lessening  of  its  transparency,  the  lens 
undergoes  with  advancing  years  an  alteration  in  form, 


DISEASES    OF    THE    CRYSTALLINE    LENS.  297 

becoming  flatter  and  less  spherical  than  in  childhood 
and  youth. 

These  alterations  in  the  structure  and  shape  of  the 
lens  are  of  great  significance.  "Old-sight,"  or  presby- 
opia, results  from  the  loss  of  elasticity  and  flattening, 
while  the  presence  or  absence  of  a  nucleus  is  of  impor- 
tance in  connection  with  the  development  of  cataract, 
since  upon  this  hinges  the  character  of  the  operative 
procedure  which  should  be  employed.  The  diminution 
of  transparency  is  chiefly  significant— for  it  does  not 
appreciably  lessen  the  acuity  of  vision — because  in  the 
aged  it  not  infrequently  leads  to  a  mistaken  diagnosis 
of  cataract,  with  its  attendant  unpleasant  consequences. 

The  lens,  being  without  nutrient  vessels,  depends 
for  its  nutrition  upon  the  lymph-stream  which  is  sup- 
plied by  the  vascular  uveal  coat.  To  reach  the  lens 
the  lymph  must  pass  through  the  capsule,  which  it  does 
chiefly  at  the  equator,  while  it  escapes  through  the  an- 
terior capsule.  The  maintenance  of  the  lens  in  a  nor- 
mal state,  it  is  evident,  will  depend  upon  the  quality  of 
the  pabulum  with  which  it  is  supplied.  If  through 
disease  of  the  eye  or  constitutional  disorder  the 
intraocular  lymph  is  materially  altered  in  character, 
the  lens,  especially  as  to  its  transparency,  is  apt  to  suffer. 

Cataract. — Although  originally  the  name  cataract, 
or  cataracta,  was  employed  to  designate  an  opacity 
which,  above  all  things,  was  held  not  to  involve  the 
crystalline  lens,  it  is  now  applied  only  to  opacities  which 
are  located  in  the  lens.  The  origin  of  the  name,  which 
dates  back  to  medieval  times,  is  interesting: 

The  Greeks  and  Romans  believed  that  the  crystalline 
lens  was  the  "seat  of  vision,"  and,  as  they  knew  that 
sight  could  be  restored  by  the  removal  of  a  cataract, 
they  were,  perforce,  driven  to  the  conclusion  that  the 


298  PREVALENT    DISEASES    OF    THE     EYE. 

opacity  which  they  displaced  from  behind  the  pupil 
was  not  the  lens,  but  an  opaque  substance  which, 
cataract-like,  had  poured  down  over  its  anterior  surface. 
Hence  the  Greek  term  hypochyma  and  the  Latin  term, 
first  used  in  medieval  times,  cataracta.  Astonishmg 
as  it  appears  to  us  in  the  light  cf  modern  methods  of 
research,  this  view  was  generally  accepted  up  to  the 
beginning  cf  the  eighteenth  century,  when  Brisseau, 
a  French  surgeon,  dissected  the  cataractous  eye  of  a 
cadaver  upon  which  he  had  previously  performed  the 
operation  of  depression,  and  discovered  that  the  opacity 
which  he  had  displaced  from  behind  the  pupil  was, 
indeed,  the  crystalline  lens.  His  discovery,  which,  of 
course,  involved  the  abandonment  of  the  view  that  the 
lens  was  essential  to  sight,  was  laid  before  the  French 
Academy,  but  did  not  receive  its  endorsement  until 
after  three  years  of  persistent  opposition. 

Cataract,  though  encountered  most  frequently  in  old 
age,  occurs  at  all  periods  of  life;  indeed,  as  is  well 
known,  it  is  at  times  of  congenital  origin.  Of  the  sev- 
eral classifications  of  cataract  the  one  of  greatest  prac- 
tical utility  is  that  which  is  based  upon  the  time  of  life 

'  at  which  the  cataract  develops,  those  which  form  after 
middle  life  being  denominated  senile  or  hard,  and  those 

^  which  occur  earlier  than  this  juvenile  or  soft,  cataracts, 
the  hardness  or  softness  of  the  cataract  being  dependent 
upon  the  presence  or  absence  of  a  firm  nucleus,  the 
formation  of  which  has  already  been  described.  Cata- 
racts are  also  classified  as  general  cataracts,  those  in 
which  the  opacity,  sooner  or  later,  involves  the  whole 
lens,  and  partial  cataracts,  in  which,  as  a  rule,  this  does 
not  happen.  Most  cases  of  congenital  and  juvenile 
cataract  and  nearlv  all  cases  of  senile  cataract  are  "gen- 
eral" cataracts.      Partial  cataracts  include  zonular,  or 


DISEASES    OF    THE    CRYSTALLINE    LENS.  299 

lamellar,  cataract,  anterior  polar  cataracts,  and  pos- 
terior polar  cataracts.  Again,  cataracts  may  be  classi- 
fied with  reference  to  their  origin,  as  congenital  cata- 
racts, idiopathic  cataracts,  complicated  cataracts  (those 
associated  with  or  dependent  upon  other  disease  of  the 
eye),  traumatic  cataracts,  and  cataracts  due  to  consti- 
tutional disorder;  and,  still  again,  with  reference  to  the 
stage  of  their  development,  as  immature,  mature,  and 
hypermatiire  cataracts;  and,  finally,  after  injuries  of 
the  lens  or  operations  upon  it  we  have  secondary  or 
capsular  cataracts. 

The  significance  of  the  first-m.entioned  classification 
is  in  its  bearing  upon  the  question  of  surgical  treatment. 
Juvenile  cataracts,  since  they  have  no  hard  nucleus, 
need  net  be  removed  from  the  eye,  but  may  be  broken 
up  with  a  needle,  and  v\ill,  in  time,  undergo  complete 
absorption.  Senile  cataracts,  on  the  other  hand,  must 
be  extracted,  since  their  firm  nucleus  will  not  undergo 
solution  in  the  fluids  of  the  eye. 

General  Cataract. — As  has  been  stated,  most  cases  of 
congenital,  of  juvenile,  and  of  senile  cataract  are  in- 
cluded under  this  head;  and,  it  may  be  added,  traumatic 
cataracts  also  are  nearly  always  of  this  character.  Gen- 
eral cataracts,  whether  juvenile  or  senile,  and  whether  of 
idiopathic  origin  or  due  to  constitutional  cause  or  to 
traumatism,  have  certain  features  in  common.  They 
are  all  attended  by  marked  and  progressive  impair- 
ment of  sight;  excepting  those  of  traumatic  origin, 
they  are  nearly  always  binocular,  though  they  often  do 
not  develop  in  the  two  eyes  concurrently;  they  are  un- 
attended by  pain  or  other  evidences  of  inflammation, 
unless  complicated  by  injury  or  other  disease  of  the  eye; 
and,  excepting  again  those  due  to  traumatism,  they  are 
usually  slow  in  forming,  this  being  especially  true  of 


300  PREVALENT    DISEASES    OF    THE     EYE. 

senile  cataracts,  which  may  be  months  or  even  years  in 
reaching  a  state  of  maturity.  The  amount  of  impair- 
ment of  vision  which  they  cause  depends  upon  the  den- 
sity of  the  opacity  and  upon  its  location  in  the  lens. 
When  they  are  fully  formed  vision  is  reduced  to  mere 
perception  of  light,  though  there  are  some  exceptions  to 
this  rule  in  the  case  of  senile  cataracts;  but,  even  when 
quite  immature,  vision  may  be  little  better  than  this, 
if  the  opacity  is  in  the  direct  line  of  sight,  that  is,  if  it 
involves  the  nucleus  of  the  lens  or  the  central  portion  of 
the  anterior  or  posterior  cortex.     On  the  other  hand,  the 


Fig.  121. — Senile  cataract,  mature  (Haab). 

existence  of  a  considerable  amount  of  opacity,  if  limited 
to  the  periphery  of  the  lens,  is  not  incompatible  with 
normal  sight,  since  this  does  not  obstruct  the  entrance 
of  light  into  the  eye  or  interfere  with  the  formation  of  a 
perfect  image  upon  the  retina. 

Even  in  fully  formed  cataract  (Fig.  121),  it  is 
important  to  remember,  the  pupil  reacts  to  light 
almost  if  not  quite  as  well  as  in  the  normal  eve. 
When  this  is  not  the  case,  or  when  light  perception  is 
imperfect  or  absent,  other  and  more  grave  disease  of 
the  eye  is  indicated. 

As  a  rule,  the  cataracts  which  occur  before  middle 


DISEASES    OF    THE    CRYSTALLINE    LENS.  3OI 

life  are  whiter  and  more  densely  opaque,  and,  therefore, 
more  conspicuous,  than  are  those  which  develop  in  the 
aged.  Indeed,  in  some  cases  of  senile  cataract,  in 
which  the  nucleus  of  the  lens  is  large  and  of  amber  color, 
the  opacity  is  so  inconspicuous  that  without  the  aid  of 
the  ophthalmoscope  the  true  condition  may  be  easily 
overlooked.  Juvenile  cataracts  are  also  less  constantly 
binocular  than  senile  cataracts,  and  are  commonly  less 
slow  in  developing ;  and,  because  they  are  oftener  due 
to  other  disease  of  the  eye  or  to  constitutional  disorder, 
the  prognosis  in  operating  upon  them  is  less  uniformly 
favorable. 

The  presence  of  a  comparatively  large  central  nu- 
cleus, the  characteristic  feature  of  senile  cataract,  is  the 
cause  of  this  variety  of  cataract  bemg  less  conspicuously 
white  than  are  those  which  occur  in  early  life.  The 
nucleus  itself  is  never  white,  and  is  seldom  densely 
opaque.  Occasionally  it  is  colorless,  but  much  oftener 
it  is  of  a  yellowish  or  amber  tint,  while  at  times  it  is 
almost  black.  As  the  layer  of  opaque  cortical  substance 
is  not  very  thick,  the  color  of  the  cataract  partakes  of  that 
of  its  nucleus,  so  that  w^e  have  in  the  aged  yellowish, 
amber-colored,  and  so-called  black  cataracts,  but  rarely 
cataracts  that  are  decidedly  white. 

In  senile  cataract  the  opacity  usually  manifests  itself 
first  in  the  cortical  layers  of  the  lens,  and,  as  has  been 
said,  it  commonly  increases  slowly,  though  in  rare 
instances  striking  exceptions  to  this  rule  are  encountered. 
While  I  have  frequently  seen  cortical  opacities  remain 
stationary  for  years,  I  have,  on  the  other  hand,  observed, 
in  three  instances,  a  senile  cataract  change  from  a  state 
of  incipiency  to  a  state  of  maturity  in  one  week's  time. 
Doubtless,  many  old  persons  go  to  their  graves  without 
being  aware  that,  for  years,  they  have  had  incipient  cat- 


302  PREVALENT    DISEASES     OF    THE    EYE. 

aracts.  This  is  not  so  remarkable,  however,  as  the 
fact,  of  not  very  rare  occurrence,  that  individuals  may 
be  bhnd  in  one  eye  from  cataract  for  months,  without 
being  conscious  that  such  is  the  case. 

One  of  the  earhest  premonitory  symptoms  of  senile 
cataract  is  the  decline  of  presbyopia,  the  acquisition 
of  so-called  "second  sight."  When  a  person,  who  for 
years  has  been  unable  to  read  without  presbyopic 
glasses,  discovers  that  he  can  now  put  them  aside  and 
read  without  their  assistance,  he  usually  congratulates 
himself,  and  is  congratulated  by  his  friends,  upon  this 
restoration  of  youthful  vision.  The  real  significance 
of  this  change  is  that  cataract  is  impending,  and  that  in 
consequence  of  the  degeneration  of  its  fibers  the  lens  is 
changing  its  shape,  becoming  more  convex,  and  so  giv- 
ing rise  to  an  acquired  myopia,  which  enables  small 
objects  to  be  seen  without  the  convex  glasses  that  were 
previously  required.  It  goes  without  saying  that  this 
improvement  in  vision  is  apt  to  be  short-lived,  and  that 
it  is  hardly  a  matter  for  congratulation. 

Our  knowledge  concerning  the  etiology  of  cataract  is 
not  as  satisfactory  as  could  be  wished.     We  know,  how- 
ever, that  the  process  which  causes  the  lens  to  become 
opaque  is  a  degenerative  and  not  an  inflammatory  one. 
•  The  lens  fibers  undergo  degeneration,  and  in  doing  so 
;  lose  their  transparency.     This   degeneration,  whether 
I    occurring  in  intrauterine  life,  in  youth,  or  in  old  age, 
is  commonly  the  result  of  faulty  nutrition,  which  may 
be  due  to  disease  of  the    eye   itself,  to   constitutional 
disorder,  or  to  senile  decay.     Among  the  constitutional 
'  disorders    which    predispose    to    the    development    of 
;  cataract  may  be  mentioned  diabetes,  inherited  syphilis, 
rachitis,     and      angiosclerosis.      A     predisposition     to 
cataract  is  also  not  infrequently  inherited,  an  unusual 


DISEASES    OF    THE    CRYSTALLINE    LENS.  303 

number    of    cataracts    being    observed    in    successive 
generations  of  certain  families. 

The  diseases  of  the  eye  most  apt  to  lead  to  opacity 
of  the  lens  are  those  which  involve  the  uveal  coat — the 
iris,  ciliary  body,  and  choroid.  Cataract  is  also  a  usual 
consequence  of  unchecked  inflammatory  glaucoma. 
Lifelong  accommodative  strain,  due  to  uncorrected 
refractive  errors,  through  the  congestion  and  inflamma- 
tion which  it  induces  in  the  inner  tunics  of  the  eye,  is,  I 
am  persuaded,  a  far  from  uncommon  cause  of  cataract. 
The  frequency  with  which  I  have  observed,  especially 
in  astigmatx  eyes,  incipient  cataract  associated  with 
miliary  choroido-retinitis,  or  with  evidences  of  pre- 
existent  choroido-retmitis  of  this  type,  long  since  forced 
this  conviction  upon  me. 
-'  Traumatic  cataract  is  usually  the  result  of  injuries 
which  involve  the  capsule  of  the  lens,  such  as  penetrat- 
ing wounds  of  the  cornea  and  lens, or  of  the  cornea,  iris, 
and  lens.  When  a  rent  is  made  in  the  capsule,  opacifi- 
cation of  the  entire  lens  commonly  follows  in  a  short  time, 
in  consequence  of  the  action  of  the  aqueous  humor  upon 
the  lens  substance.  In  rare  instances,  when  the  W'Ound 
in  the  capsule  is  small  it  may  close,  and  there  may  result 
only  a  circumscribed  and  stationary  opacity,  which, 
unless  centrally  located,  may  cause  little  or  no  impair- 
ment of  vision.  Usually  when  injured  the  lens  swells 
considerably,  and  the  pressure  which  it  then  exerts 
upon  the  iris  and  ciliary  body  may  excite  inflam- 
mation of  these  structures;  secondar}^  glaucoma  may 
also  be  brought  about  in  this  way.  Severe  concussion 
of  the  eyeball,  even  vvhen  unattended  by  rupture  of  the 
lens  capsule,  is  at  times  followed  by  the  development 
of  cataract. 

Congenital  cataract,  v;hich  is  almost  invariably  binoc- 


304  PREVALENT    DISEASES    OF    THE    EYE. 

ular,  is  caused  by  disturbed  nutrition  or  inflammation 
of  the  eye  in  intrauterine  life.  An  inherited  predispo- 
sition to  this  variety  of  cataract  is  especially  common. 

To  the  general  practitioner  the  most  important  matter 
with  reference  to  cataract  is  its  diagnosis,  the  ability  to 
recognize  its  existence,  and  to  determine  the  stage  of  its 
development;  for,  unquestionably,  the  operative  treat- 
ment of  cataract  should  not  be  undertaken  except  by 
those  who  have  had  special  training  in  this  branch 
of  surgery.  The  physician  who  is  able  to  diagnosticate 
cataract  in  its  early  stages,  and  hence  to  give  a  correct 
prognosis  as  to  the  impending  loss  of  sight,  deserves, 
and  will  receive,  no  little  credit;  and  if,  further,  he  is 
qualified  to  decide  as  to  its  maturity — whether  or  not  it 
has  reached  the  stage  when  an  operation  should  be 
performed — he  is  in  a  position  to  give  to  his  patient 
advice  of  much  value. 

As  a  rule,  when  a  cataract  has  progressed  far  enough 
to  appreciably  impair  sight  its  recognition  is  not  a 
matter  of  great  difficulty,  even  to  the  non-specialist. 
This  observation,  as  has  been  intimated,  is  especially 
true  of  cataract  occurring  in  early  life;  but  it  is  true  also 
of  senile  cataract,  if  he  will  make  use  of  the  diagnostic 
aids  which  are  within  his  reach. 

To  begin  with,  familiarity  in  the  employment  of 
"oblique  illumination,"  which,  as  explained  in  the 
chapter  upon  "diagnosis,"  is  not  difficult  of  acquire- 
ment, will  enable  him  to  distinguish  with  certainty 
between  lenticular  and  corneal  opacities,  between  opac- 
ities situated  behind  and  in  front  of  the  plane  of  the  iris. 
It  will  enable  him  also  to  detect  slight  opacities  in  the 
lens,  in  its  anterior  portion  especially,  which  might 
otherwise  escape  observation.  Again,  the  use  of  an 
evanescent  mydriatic  (a  one  per  cent,  solution  of  hom- 


PI.ATE  VIII. 


Fig. 


Fig.  3. 


Fig.  4. 


Fig.  I. — Mature  cataract,  as  seen  by  daylight  or  bv  oblique  illumination 
(after  Sichel). 

Fig.  2. — Immature  cataract,  as  seen  bv  transmitted  light  (with  ophthal- 
moscope or  ear-mirror). 

Fig.  3. — Zonular  cataract,  as  seen,  with  pujjil  dilated,  by  oblique  illu- 
mination (modified  after  Sichel). 

Fig.  4. — Zonular  cataract,  as  seen  with  ophthalmoscope  or  ear-mirror, 
(pupil  dilated  by  atropin)    (after  Jaeger). 


DISEASES    OF    THE    CRYSTALLINE    LENS.  305 

atropin  hydrobromate  or  a  five  per  cent,  solution  of 
euphthalmin  hydrochlorate),  by  exposing  the  lens  more 
completely  to  inspection,  will  afford  him  further  val- 
uable assistance.  With  a  widely  dilated  pupil,  and  the 
aid  of  oblique  illumination,  only  opacities  situated  in  the 
periphery  of  the  lens  or  near  its  posterior  pole  are  likely 
to  escape  detection,  and  the  former,  as  has  been  stated, 
are  not  apt  to  disturb  vision  (Plate  VIII,  Fig.  i). 

The  error  into  which  the  general  practitioner,  even 
with  these  aids,  is  most  apt  to  fall,  is  in  mistaking  the 
apparent  opacity  of  the  senile  lens  for  true  cataract. 
For,  with  the  pupil  dilated,  and  the  light  focused  upon 
the  exposed  lens,  the  yellowish  color  and  the  seeming 
opacity  of  the  nucleus  common  in  the  aged  are  made 
especially  conspicuous,  so  that  the  expert  even  may  be 
inclined  to  believe  that  a  cataract  is  present.  Any 
doubts  that  he  may  entertain  upon  this  point,  however, 
are  soon  dispelled  by  the  use  of  the  ophthalmoscope, 
since  by  transmitted  light  the  apparent  opacity,  made 
conspicuous  by  oblique  illumination,  disappears,  and 
only  such  opacity  as  is  real,  as  constitutes  cataract,  is 
seen.  Real  opacities  observed  in  this  way,  the  ophthal- 
moscopic mirror  being  held  about  twelve  inches  from 
the  eye,  no  longer  appear  gray  or  yellowish,  as  they  do 
by  focused  light,  but,  if  the  cataract  is  incomplete,  are 
seen  as  blackish  spokes  or  flocculi,  or  as  a  dark  central 
area,  against  the  red  background  of  the  eye  (Plate  VIII, 
Fig.  2). 

This  use  of  the  ophthalmoscope  does  not  require  spe- 
cial training,  so  that  those  not  skilled  in  ophthalmos- 
copy may  make  such  an  examination  satisfactorily; 
and,  if  an  ophthalmoscope  be  not  at  command, 
an  ear  or  throat  mirror  will  be  found  to  answer 
almost    as    well,  provided    the    light    be    placed    at    a 


306  PRFVALENT    DISEASES    OF    THE     EYE. 

greater  distance  than  usual  from  the  eye  under  exam- 
ination, so  that  the  illumination  of  the  pupil  shall  not 
be  too  intense.  In  using  such  a  mirror  as  a  substitute 
for  the  ophthalmoscope,  the  observer  must,  of  course, 
look  through  the  opening  in  its  center,  otherwise  the 
pupil  will  appear  not  red  but  black,  and  the  lenticular 
opacities  will  not  be  seen.  Ill-defined  opacities  limited 
to  the  periphery  of  the  lens  or  situated  at  its  posterior 
pole  are  comparatively  difficult  of  detection  even  by 
transmitted  Hght,  and  will  hardly  be  recognized  by 
those  unfamiliar  with  the  use  of  the  ophthalmoscope. 

The  steamy  appearance  of  the  lens,  exaggerated  by 
the  mistiness  of  the  cornea  and  vitreous  humor,  ob- 
served in  inflammatory  glaucoma  might  be  mistaken 
for  cataract;  but,  as  the  inflammatory  symptoms,  the 
high  tension,  etc.,  point  unmistakably  to  the  true  con- 
dition, an  error  of  this  character  is  inexcusable.  With 
more  warrant,  the  opaque  exudate  occluding  the  pupil 
which  is  at  times  observed  as  a  sequel  of  iritis  may  lead 
to  a  mistaken  diagnosis  of  cataract.  Inspection  by 
oblique  illumination,  how^ever,  would  show  that  the 
opacity  was  upon  and  not  beneath  the  capsule,  and  the 
application  of  a  mydriatic,  by  the  failure  of  the  pupil  to 
respond  or  by  its  irregular  dilatation,  would  in  all  prob- 
ability demonstrate  the  existence  of  posterior  synechire. 

The  subjective  symptoms  of  cataract,  though  not  so 
pathognomonic  as  the  objective  signs,  are  nevertheless 
of  diagnostic  value.  Mention  has  already  been  made 
of  one  of  the  most  characteristic  premonitory  symptoms 
— the  acquisition  of  "second  sight."  It  should  be 
remarked,  however,  that  though  this  symptom  indicates 
very  clearly  what  is  impending,  it  may,  in  exceptional 
instances,  antedate  by  many  months  the  development 
of  such  an  amount  of  lenticular  opacity  as  will  seriously 


DISEASES    OF    THE    CRYSTALLINE    LENS.  307 

impair  vision.  The  slowly  progressive  failure  of  sight, 
unattended  by  inflammatory  symptoms,  observed  in 
cataract  is  not,  in  itself,  characteristic,  for  vv^e  meet  with 
this  in  other  conditions,  such,  for  example,  as  progres- 
sive atro£hy^_of  the  optic  nerve;  but  when  it  occurs 
without  loss  or  diminution  of  pupillary  reaction  to  light, 
the  presumption  is  very  strong  that  it  is  due  to  advanc- 
ing lenticular  opacity.  Monocular  diplopia  or  polyopia, 
most  apt  to  be  observed  in  regarding  a  bright  light  or 
a  brilliantly  illuminated  object,  such  as  the  moon,  is 
another  symptom  strongly  suggestive  of  cataract,  since 
it  rarely  occurs  except  in  consequence  of  incomplete 
opacity  of  the  lens,  which  causes  the  light  in  its  passage 
toward  the  retina  to  be  broken  up  into  separate  pen- 
cils. Better  vision  in  subdued  light,  as  after  the  setting 
of  the  sun,  is  another  suggestive  symptom,  often  men- 
tioned by  patients  w^ith  incipient  cataract,  and  which 
has  its  explanation  in  the  increased  size  of  the 
pupil  under  such  circumstances.  In  line  with  this  is 
the  improvement  in  vision  which  often  results  in 
partially  developed  cataract  from  the  application  of  a 
mydriatic. 

Finally,  it  is  to  be  stated,  cataract  should  be  suspected, 
and  should  be  carefully  searched  for,  whenever  there  is 
failure  of  sight,  without  other  evident  cause,  in  persons 
who  have  reached  or  who  have  passed  middle  age, 
in  individuals  known  to  be  suffering  with  diabetes,  and 
in  infants  or  children  with  congenitally  defective 
vision. 

The  determination  of  the  maturity  or  "ripeness" 
of  cataract  is  not  so  simple  a  matter  as  we  were  formerly 
taught  to  believe.  Not  very  many  years  ago,  a  cataract 
was  held  to  be  mature  if  with  the  affected  eye  there  was 
inability  to  count  fingers,  while  it  was  regarded  as  imma- 


308  PREVALENT    DISEASES    OF    THE     EYE. 

ture  if  this  amount  of  vision  was  present.  This  "rule 
of  thumb  "  is  now  known  to  be  subject  to  so  many  excep- 
tions that  it  can  no  longer  be  regarded  as  a  trustworthy 
guide.  Before  speaking  of  these  exceptions,  it  will  be 
w^ell  to  consider  what  is  meant  by  a  mature  or  ripe 
cataract. 

A  surgically  mature  cataract  is  one  that  is  in  a  favor- 
able condition  for  operation — one  that  may  be  easily 
and  completely  removed.  In  other  words,  it  is  a  cat- 
aract in  which  all  of  the  lens  fibers  have  undergone  de- 
generation, and  in  which,  as  one  of  the  consequences 
of  this  change,  the  intimate  connection  that  normally 
exists  between  the  lens  proper  and  its  capsule  has  been 
lost.  Such  a  cataract  has  been  aptly  compared  to  a 
ripe  fruit,  w^hich  may  be  readily  removed  from  its  rind. 
Now,  it  is  a  fact  that  there  does  not  exist  a  constant  rela- 
tion between  this  condition  and  the  degree  of  impair- 
ment of  sight.  That  is  to  say,  there  are  immature 
cataracts  which  reduce  vision  to  mere  light  perception, 
while,  on  the  other  hand,  there  are  mature  cataracts, 
cataracts  in  a  thoroughly  satisfactory  condition  for  oper- 
ation, which  impair  sight  much  less  markedly,  not 
only  ability  to  count  fingers  at  several  feet,  but  to 
distinguish  large  letters  at  this  distance  with  no  great 
difficulty,  being  retained.  It  is  evident,  therefore,  that 
there  are  other  factors,  besides  the  amount  of  sight  im- 
pairment, which  must  be  taken  into  account  in  deter- 
mining the  surgical  maturity  of  a  cataract.  The 
important  point  is  to  know  how  completely  the  lens 
has  undergone  degeneration. 

If  w^hen  inspected  by  oblique  illumination  portions 
of  the  lens  are  seen  to  be  still  transparent,  the  cataract 
is  manifestly  immature,  the  degeneration  of  the  lens 
fibers  is  incomplete.     The  flocculent,  glistening,  mother- 


DISEASES    OF    THE    CRYSTALLINE    LENS.  309 

of-pearl  appearance  frequently  seen  in  senile  cataracts 
especially,  and  due  to  a  lack  of  uniformity  in  the  degen- 
eration of  the  lens  substance,  is  another  evidence  of 
immaturity,  although  when  this  condition  is  present 
vision  is  seldom  better  than  light  perception. 

The  cataracts  which,  notwithstanding  their  maturity, 
permit  such  a  considerable  degree  of  vision  as  has  been 
described  (ability  to  count  fingers,  etc.)  are  commonly 
observed  in  persons  who  are  well  advanced  in  years — 
over  sixty-five  or  seventy  years  of  age — and  in  whom, 
therefore,  the  nucleus  of  the  lens  is  relatively  large  and 
the  overlying  layer  of  cortical  substance  comparatively 
thin.  The  most  striking  examples  of  cataract  of  this 
character  are  those  which  exhibit  a  decidedly  yellowish 
or  amber  color.  It  is  the  large  size  and  the  comparative 
clearness  of  the  nucleus  in  such  cataracts  that  explains 
the  relatively  good  vision  retained,  and  also  the  fact  that 
not  infrequently  when  the  ophthalmoscope  is  used  a 
sufficient  amount  of  light  reaches,  and  is  reflected  from, 
the  fundus  of  the  eye  to  give  a  reddish  pupillary  reflex, 
a  thing  which  is  never  observed  in  the  unripe,  mother-of- 
pearl  cataract  or  in  even  the  far  from  mature  juvenile 
cataract. 
I  Almost  without  exception  these  amber-colored,  seem- 
I  ingly  unripe,  cataracts  prove  to  be  in  an  ideal 
.  state  for  operation;  that  is,  they  are  easily  extruded 
from  the  capsule,  and  if  any  bits  of  the  cortical  sub- 
stance are  left  behind  they  are  dissolved  speedily  and 
soon  disappear,  because  they  have  undergone  pre- 
viously such  complete  degeneration.  In  this  respect 
they  behave  entirely  unlike  the  clear  lens  substance  of 
an  immature  cataract  when  left  in  situ,  which  increases 
in  bulk  as  it  becomes  opaque,  resists  absorption  for  a 
considerable  time,  is  apt  to  excite  inflammation  of  the 


310  PREVALENT    DISEASES    OF    THE     EYE. 

iris,  and  may  in  this  way  lead  to  the  formation  of  a  sec- 
ondary cataract. 

Treatment. — An  important  point  to  be  impressed  upon 
the  general  practitioner  with  regard  to  the  treatment  of 
cataract  is  that  the  only  effectual  method  of  dealing  u-ith 
the  corrdition  is  by  operation.  One  frequently  hears 
of  the  claims  put  forth  by  charlatans  that  they  can  cure 
cataract,  that  they  can  dissipate  lenticular  opacities,  by 
means  other  than  operative;  but,  without  exception, 
these  claims,  when  subjected  to  investigation,  have 
proved  to  be  entirely  w^ithout  justification,  to  be,  in  fact, 
purely  fraudulent. 

In  the  incipient  stage  of  cataract,  when  the  opacity 
is  confined  to  the  periphery  of  the  lens,  if  the  ophthal- 
moscope affords  evidence  to  warrant  the  belief  that  the 
lenticular  changes  are  dependent  upon  a  low  grade  of 
choroido-retinitis,  it  is  proper  to  take  measures  to  com- 
bat this  latter  condition;  for,  if  this  can  be  done  success- 
fully, there  is  ground  for  hope  that  the  develop- 
ment of  the  cataract  may  be  arrested  or,  at  least,  re- 
tarded. The  most  effectual  means  of  doing  this  consist 
in  the  careful  correction  of  any  refractive  errors  that 
may  be  found  to  be  present;  in  moderation  in  the  use 
of  the  eyes;  in  inducing  by  suitable  measures  regular 
action  of  the  bowels,  and  in  the  administration  of  small 
doses  of  biniodid  of  mercury  (gr.  -jV  to  -3V)  or  of  po- 
tassium iodid.  If,  how^ever,  the  opacity  has  advanced 
so  far  as  materially  to  impair  sight,  such  measures  will 
be  without  avail. 

During  the  stage  of  immaturity,  while  the  cataract 
perhaps  is  developing  slowly,  temporary  but  greatly 
appreciated  improvement  in  vision  may  be  obtained,  in 
some  instances,  by  keeping  the  pupil  moderately  dilated 
through  the  application    of   a    mydriatic.     The    cases 


DISEASES    OF    THE    CRYSTALLINE    LENS.'  3II 

in  which  this  is  possible  are  those  in  which  the  opacity 
is  hmited  to  the  central  portion  of  the  lens  or,  at  least, 
is  more  dense  there  than  it  is  in  those  parts  of  the  lens 
that  are  commonly  covered  by  the  iris.  A  weak  solution 
of  atropin  (gr.  |  togi)  is  best  adapted  to  this  purpose, 
and  need  not  be  applied,  as  a  rule,  oftener  than  once 
in  three  or  four  days.  A  single  application  will  suffice 
to  determine  whether  or  not  this  will  prove  helpful. 
In  using  so  weak  a  solution  of  atropin  there  is  little  dan- 
ger, even  in  the  aged,  of  causmg  an  abnormal  increase 
of  intraocular  tension;  but  the  possibility  of  this  should 
be  borne  in  mind,  and  should  any  evidences  of  an  in- 
duced glaucoma  be  observed,  the  mydriatic  action  of 
the  atropin  must  be  neutralized  at  once  by  the  use  of 
eserin. 

It  may  be  well  to  add  that  one  should  take 
care  that  the  temporary  improvement  in  the  patient's 
vision  caused  by  the  mydriasis  does  not  lead  him  to 
entertain  false  hopes  that  he  is  being  cured.  It  is  a 
common  practice  with  quacks  to  employ  a  mydriatic 
in  incipient  cataract  for  this  very  purpose,  and  it  is  not 
difficult  for  them  to  persuade  their  dupes  that  an  agent 
which,  as  the  result  of  a  single  application,  has  made 
so  marked  an  improvement  in  vision  will  in  a  short 
time  effect  a  complete  cure. 

Another  practical  suggestion,  having  to  do  with  the 
incipient  stage  of  cataract,  is  as  to  the  unwisdom  of 
telling  the  average  patient  that  a  cataract  is  beginning 
to  develop  in  his  eye,  which  will  in  time  lead  to  loss  of 
sight.  Months  may  elapse,  in  some  instances  even 
years,  after  the  ophthalmoscope  has  revealed  the  pres- 
ence of  slight  peripheral  opacity  of  the  lens  before  a  con- 
siderable impairment  of  vision  occurs,  and  during  all 
this  time  the  individual  may  be  relieved  of  the  dread  of 


312  PREVALENT    DISEASES     OF    THE    EYE. 

impending  blindness,  and  the  unhappiness  to  which  this 
is  sure  to  give  rise,  if  the  information  gained  by  our  in- 
spection of  the  eye  be  kept  from  him.  It  is  a  case  to 
which  the  proverb,  "where  ignorance  is  bhss,"  etc., 
is  strikingly  applicable.  It  is  proper,  however,  for 
our  own  protection,  if  for  no  other  reason,  that  some 
member  of  the  patient's  family  should  be  made  aware 
of  the  true  condition.  On  the  other  hand,  if  the  sight 
is  already  decidedly  impaired  it  is  best  to  tell  the  patient 
frankly  what  the  trouble  is,  since  we  are  then  in  a  posi- 
tion to  give  him  a  very  favorable  prognosis,  and  so 
relieve  his  mind  of  much  anxiety. 

The  question  often  arises  as  to  the  advisability  of 
operating  for  cataract  upon  one  eye,  when  the  sight  of 
the  fellow-eye  is  as  yet  unimpaired.  It  may  be  stated, 
as  a  general  truth,  that  the  improvement  in  vision  gained 
by  doing  this  will  not  be  very  considerable;  for 
the  unaffected  eye  will  still  be  used  for  all  accurate 
seeing.  The  field  of  vision,  however,  will  be  widened, 
and  there  are  certain  other  advantages  to  be  gained 
which  deserve  consideration.  In  the  first  place,  if  the 
patient  is  still  voung,  the  improvement  in  personal  ap- 
pearance resulting  from  the  removal  of  so  serious  a 
blemish  as  is  caused  by  the  presence  of  a  monocular 
caratact  is  a  matter  not  alwavs  to  be  ignored.  Again, 
and  this  applies  more  particularlv  to  cases  in  which  there 
are  incipient  evidences  of  the  formation  of  a  cataract 
in  the  fellow-eye,  it  is  a  great  comfort  to  the  patient  to 
feel  that  one  eye  has  been  operated  upon  successfully, 
and  that  he  will  have  this  eye  to  fall  back  upon  when 
the  sight  of  the  other  finally  fails.  Still  another  con- 
sideration is  that  cataracts  in  time,  after  having  passed 
through  the  stage  of  maturity,  tend  to  become  overripe, 
or  hypermature,  in  which  condition,  owing  to  the  tough- 


DISEASES    OF    THE    CRYSTALLINE    LENS.  3I3 

ening  of  the  capsule  and  the  secondary  degenerative 
changes  in  the  lens,  they  are  in  a  less  favorable  state 
for  operation. 

On  the  whole,  taking  into  consideration  the 
infrequency  at  the  present  day  of  unfavorable  re- 
sults in  operations  for  cataract,  it  is  best,  I  think, 
if  there  is  evidence  of  beginning  lenticular  opacity  in 
the  relatively  good  eye,  to  operate  upon  the  other  eye, 
provided  the  cataract  is  fully  mature.  On  the  other 
hand,  if  it  is  immature,  the  operation  should  be 
deferred,  at  least  until  the  sight  of  the  better  eye  has 
become  appreciably  impaired.  And  here  it  may  be 
remarked  that  when,  as  frequently  happens,  the  lens 
opacity  develops  concurrently  in  the  two  eyes,  so  that 
the  sight  of  each  is  much  impaired,  there  is  a  disposition 
at  the  present  day,  more  especially  in  dealing  with 
persons  who  have  reached  the  age  of  sixty-five  or 
seventy,  to  operate  upon  the  eye  in  which  the  opacity 
may  be  more  advanced,  without  waiting  for  the 
cataract  to  become  fully  mature,  the  reason  for  this 
being  that  in  the  aged  the  nucleus  of  the  lens  is  so 
large  and  the  cortical  substance  so  inconsiderable  in 
amount  that,  even  when  it  has  not  undergone 
complete  degeneration,  it  is  not  apt  to  give  rise  to 
complications. 

In  persons  under  the  age  mentioned,  if  the  sight  of 
each  eye  is  much  affected,  and  the  cataract  in  each  is 
still  immature,  the  procedure  of  Forster  is  indicated. 
This  consists  in  the  performance  upon  one  eye  of  a 
preliminary  iridectomy,  accompanied  by  a  bruising 
or  "trituration"  of  the  lens.  The  purpose  of  this 
procedure  is  to  hasten  the  ripening  of  the  cataract,  so 
that  its  removal  may  be  undertaken  sooner  than  other- 
wise would  be  practicable.     The  desired  result  is  not 


314  PREVALENT    DISEASES    OF    THE     EYE. 

always  secured;  but  not  infrequently,  within  five  or  six 
weeks  of  the  performance  of  the  operation,  the  cataract 
will  have  reached  a  state  of  maturity  which  it  might  not 
have  reached  in  many  months  had  it  been  left  to  ripen 
in  the  usual  way. 

Although  the  operation  of  cataract  extraction  was 
known  to  the  Romans  of  the  period  of  the  Empire, 
and  was  practised  during  the  middle  ages  by  the  Arab- 
ians, it  was  not  revived  in  Europe  until  the  middle  of 
the  eighteenth  century;  and  long  after  that,  indeed  as 
late  as  the  middle  of  the  last  century,  the  real  indications 
for  its  performance  in  preference  to  the  more  easily 
executed  operations  of  couching  or  depression  and  of 
discission  were  but  imperfectly  understood.  At  the 
present  day  the  manner  in  which  a  cataract  shall  be 
operated  upon — whether  it  shall  be  "needled"  and 
allowed  to  undergo  solution  in  the  eye  or  shall  be  ex- 
tracted from  the  eye — is  determined  by  its  consistency, 
by  its  hardness  or  softness,  that  is  to  say,  by  whether 
it  contains  or  does  not  contain  a  firm  nucleus.  Hence 
it  is  that  all  senile  cataracts,  indeed,  all  cataracts  occur- 
ring in  persons  over  thirty  years  of  age,  are  extracted; 
while  all  juvenile  cataracts  are  needled. 

Formerly,  in  the  operation  of  discission,  as  well  as  in 
that  of  couching,  the  cataract  needle  was  introduced 
through  the  sclera,  and  the  lens  was  attacked  from 
behind.  In  the  modern  operation  of  discission,  on  the 
contrary,  the  needle  is  always  introduced  through  the 
cornea,  and  the  lens  is  attacked  through  the  anterior  cap- 
sule, in  which  a  more  or  less  extensive  rent  is  made.  The 
purpose  of  this  is  to  expose  the  cataract  to  the  action 
of  the  aqueous  humor,  which  in  time  effects  its  solution 
and  absorption.  This  process  is  a  slow  one,  and  com- 
monly consumes  several  months,  and  not  infrequently 


DISEASES    OF    THE    CRYSTALLINE    LENS.  3I5 

more  than  one  needling  is  required.  It  is,  however, 
a  much  safer  procedure,  especially  in  infants  and 
children,  than  the  operation  of  extraction,  and  is  less 
liable  to  accidental  or  other  complications.  At  the 
time  of  the  operation  the  pupil  must  be  widely  dilated 
by  atropin,  and  this  dilatation  must  be  maintained  until 
the  absorption  of  the  lens  is  complete.  Under  the  in- 
fluence of  cocain  the  operation  is  painless;  but  in  young 
children  it  is  best  usually  to  employ  a  general  anes- 
thetic, the  primary  anesthesia  induced  by  chloroform 
being  sufficient,  as  the  needling  requires  but  a  few 
moments.  Unless  complications  occur  there  is  little 
or  no  after-suffering,  and,  except  for  a  few  days,  the 
patient  need  be  subjected  to  but  slight  restraint. 

There  are  two  methods  of  operating  upon  hard,  or 
senile,  cataracts  in  vogue  at  the  present  day — simple 
extraction  and  combined  extraction,  01  extraction  with 
iridectomy.  Each  has  its  advocates,  though  the  latter 
procedure,  because  less  liable  to  unpleasant  com- 
plications, is  probably  more  than  holding  its  own. 
For  myself,  as  the  result  of  a  considerable  experience 
with  both  methods,  I  have  come  to  prefer  combined 
extraction,  and  for  some  years  have  operated  by  this 
method  only. 

With  the  eye  thoroughly  cocainized,  the  operation 
of  cataract  extraction,  whichever  procedure  be  em- 
ployed, is  seldom  attended  by  pain  that  is  at  all  intoler- 
able, and  frequently  is  entirely  painless.  The  making 
of  the  corneal  section  is  hardly  ever  painful,  for  the 
cornea  is  thoroughly  anesthetized;  but  as  the  anesthesia 
of  the  ins  is  usually  less  complete,  it  is  not  uncommon 
for  some  pam  to  be  experienced  when  it  is  drawn  out 
and  cut  in  the  combined  operation,  or  compressed  and 
stretched  in  the  extrusion  of  the  lens  in  simple  extrac- 


3l6  PREVALENT    DISEASES    OF   THE     EYE. 

tion.  Some  discomfort  in  the  eye,  at  times  amounting 
to  pain,  is  often  felt  during  the  twelve  hours  following 
the  operation;  but,  if  no  complications  occur,  this  usu- 
ally constitutes  the  sum  of  the  patient's  suffering.  For 
three  days  it  is  best  that  he  should  be  kept  in  bed,  with 
both  eyes  closed;  but  on  the  fourth  he  may  sit  up  and 
have  the  use  of  the  unoperated  eye.  At  the  end  of  a 
week  the  dressings  are  left  off  the  other  eye,  and  usually 
at  the  end  of  two  weeks  he  is  able  to  leave  the  hos- 
pital, being  provided  with  a  pair  of  smoke-tinted  glasses, 
to  be  worn  until  the  eye  is  quite  free  from  irritation  and 
in  a  favorable  condition  for  the  adjustment  of  the  "cat- 
aract glass,"  which,  of  course,  is  essential  to  clear 
vision,  and  which,  thenceforth,  he  will  wear  contin- 
uously. 

As  to  the  chances  of  an  operation  for  senile  cataract 
being  successful,  it  may  be  said  that  with  the  great 
help  afforded  by  cocain,  with  the  means  at  command 
for  lessening  the  likelihood  of  post-operative  accidents 
(Fig.  122),  and  with  the  careful  antiseptic  precautions 
employed  at  the  present  day  the  percentage  of  failures 
in  the  hands  of  experienced  operators  is  extremely 
small — scarcely  more  than  four  per  cent.  In  spite 
of  every  precaution,  about  two  per  cent,  of  the  eyes 
operated  upon  are  lost  by  infection,  the  infection 
in  some  instances  doubtless  being  entogenous.  The 
other  two  per  cent,  of  failures  is  usually  attributable 
to  unruly  behavior  upon  the  part  of  the  patient,  either 
during  or  after  the  operation,  to  the  existence  of  other 
disease  of  the  eye  apart  from  the  cataract,  or  to  some 
misadventure  in  the  performance  of  the  operation. 

In  one  hundred  consecutive  cases  of  cataract  extrac- 
tion reported  by  the  author  a  few  years  since*  the  opera- 

*  "American  journal  of  Ophthalmology,"  Dec,  1899. 


DISEASES    OF    THE    CRYSTALLINE    LENS. 


Z^l 


tion  was  successful  in  ninety  cases,  the  vision  obtained 
varying  from  ^°  to  ^j^.^,  and  partially  successful,  vision 
being  less  than  ^°,  in  six  cases,  while  two  eyes  were  lost 
from  infection,  and  in  two  others  no  improvement  in 
vision  resulted,  though  recovery  from  the  operation  was 
smooth,   owing  to   pre-existent  disease   of  the    retina. 


Fig.  122. — Dr.  Murdoch's  protective  shield  as  applied  after  cataract  ex- 
traction. The  left  eye  is  closed  with  a  pad  of  gauze  and  absorbent  cotton — 
a  convenient  dressing  in  less  delicate  operations. 


In  ninety-three  operations  performed  since  this  report 
there  have  been  four  failures,  two  from  suppuration — 
exactly  the  same  as  in  the  first  series — and  two  from 
other  causes,  a  percentage  of  failures  tor  the  whole  series 
of  nearly  two  hundred  cases  of  slightly  less  than  3.11. 
Among  the  conditions  which  militate  against  the 
success  of  the  operation  of  extraction  of  cataract  may 


3l8  PREVALENT    DISEASES    OF    THE     EYE. 

be  mentioned  the  existence  of  diabetes.  This  should 
not  be  regarded  as  a  contraindication  to  its  perform- 
ance, however,  as  in  the  great  majority  of  such  cases 
the  operation  proves  successful.  The  presence  of  an 
arcus  senilis  was  formerly  regarded  as  influencing  the 
prognosis  unfavorably,  but  this  is  now  known  not  to  be 
the  case.  There  is,  moreover,  little  ground  for  the 
popular  belief  that  advanced  age  lessens  materially 
the  chances  of  success  of  an  operation  for  cataract. 
One  often  hears  of  persons  who  hesitate  to  submit  to 
operation  because  they  fear,  or  have  been  told,  that  they 
are  too  old  to  undergo  it.  My  own  experience  is,  and 
it  agrees  with  that  of  other  ophthalmic  surgeons,  that 
cataract  operations  upon  octogenarians,  if  for  their  age 
they  are  in  fairly  good  health,  are  as  apt  to  be  successful 
as  are  those  performed  upon  persons  who  have  not  yet 
reached  the  biblical  threescore  years  and  ten. 

Another  popular  misapprehension  is  as  to  the  likeli- 
hood of  a  cataract  returning  after  it  has  been  removed. 
"If  I  have  my  eye  operated  upon,  can  I  feel  any  assur- 
ance that  the  cataract  will  not  return  ?"  is  the  way  it  is 
often  put.  Once  removed,  a  cataract,  strictly  speaking, 
never  returns;  but  capsular  opacities,  sometimes  spoken 
of  as  secondary  cataracts,  occasionally  develop  even 
after  the  most  successful  operations,  and  may  interfere 
with  vision  to  such  a  degree  as  to  require  "needling." 
And  in  this  circumstance,  doubtless,  is  to  be  found  the 
explanation  of  the  misconception  in  question. 

Not  only  do  senile  cataracts  require  to  be  extracted, 
but,  under  certain  circumstances,  soft,  or  juvenile,  cata- 
racts as  well  must  be  dealt  with  in  this  wav.  For  ex- 
ample, a  traumatic  cataract  occurring  in  a  young  person 
may  become  so  swollen,  and  the  anterior  chamber  so 
filled  with  opaque  lens  substance,  as  to  cause  much  irrita- 


DISEASES    OF    THE    CRYSTALLINE    LENS.  3I9 

tion,  and,  perhaps,  induce  a  glaucomatous  condition; 
and  a  similar  state  of  affairs  may  follow  the  operation 
of  discission  performed  upon  a  soft  cataract.  Under 
such  circumstances,  the  partial  or  complete  removal 
of  the  cataract  is  called  for,  and  this  is  accomplished 
by  a  linear  extraction  or  by  what  is  known  as  suction 
extraction.  In  the  one  case  a  linear  incision,  about  5 
mm.  in  length,  is  made  in  the  cornea,  a  little  in  front 
of  the  plane  of  the  iris,  and  the  lens  substance  is  coaxed 
out  by  carefully  exerted  pressure  and  counter-pressure. 
In  the  other,  a  similar  incision  is  made,  and  the  nozzle 
of  a  suction  syringe,  especially  adapted  to  the  purpose, 
is  introduced  into  the  anterior  chamber,  and  the  semi- 
fluid cataractous  substance  is  cautiously  sucked  out. 
Successfully  carried  out,  these  procedures  not  only 
relieve  the  irritation  and  reduce  the  tension  of  the  eye, 
but  greatly  hasten  the  restoration  of  vision,  for  which 
purpose  alone  they  are  sometimes  employed. 

It  is  well  to  remember,  in  dealing  with  congenital 
cataracts,  that  it  is  not  safe  to  postpone  operating  too 
long  after  birth,  since  in  the  new-born  permanent 
amblyopia  is  apt  to  result  from  nonexercise  of  the  retina. 
In  adults  there  is  no  risk  of  this  sort. 

In  all  operations  for  cataract  a  rule  which  I  have  in- 
variably adhered  to,  and  which  I  think  should  never 
be  departed  from,  is  to  operate  upon  only  one  eye  at  a 
time.  For,  should  the  first  operation  not  prove  success- 
ful, the  experience  gained  with  this  eye  may  be  very 
helpful  when  we  come  to  deal  with  the  other  eye. 
Again,  an  intercurrent  infection  may  involve  both  eyes, 
or  the  failure  of  the  operation  upon  one  eye  may  lead 
to  complications  in  the  fellow-eye.  In  a  word,  as  the 
homely  proverb  has  it,  we  should  never  put  all  our  eggs 
in  one  basket. 


320  PREVALENT    DISEASES    OF    THE     EYE. 

Exceptionally,  after  excellent  sight  resulting  from  a 
cataract  operation  has  been  enjoyed  for  months,  a  grad- 
ual decline  in  vision  may  occur.  This  is  due  usually 
to  a  wrinkling  of  the  posterior  half  of  the  lens  capsule, 
and  if  the  disturbance  of  vision  is  considerable  a  needle 
operation  is  called  for;  that  is,  a  central  rent  should  be 
torn  in  the  capsule  with  a  cataract  needle  or  needle- 
knife.  This  operation,  under  cocain  anesthesia,  is  not 
painful,  but  it  demands  rigid  antiseptic  precautions;  the 
outcome  is  commonly  most  satisfactory. 

Partial  Cataract. — Partial  cataracts,  which  fre- 
quently are  of  congenital  origin,  differ  from  general 
cataracts,  as  has  been  said,  in  that  they  show  little  or  no 
disposition  to  involve  the  whole  lens,  the  opacity  usually 
remaining  circumscribed  and  stationary'  throughout 
life.  There  are  several  varieties  of  partial  cataract, 
which  differ  radically  as  to  their  appearance,  as  to  their 
etiology,  and  as  to  their  effect  upon  vision.  In  two  of 
these  the  opacity  is  limited  to  the  anterior  pole  of  the 
lens.  These,  therefore,  are  denommated  anterior  polar 
cataracts.  There  are  also  two  varieties  in  which  the 
opacity  is  confined  to  the  posterior  pole  of  the  lens,  and 
which  are  known  as  posterior  polar  cataracts.  Finally, 
there  is  the  variety  known  as  zonular,  or  lamellar,  cata- 
ract, in  which  there  is,  within  the  lens,  a  hollow,  oblate 
sphere  of  opacity,  which  encloses,  and  is  surrounded  by, 
clear  lens  substance. 
K  Anterior  Polar  Cataract. — Of  the  two  \arieties  of 
anterior  polar  cataract  the  one  less  frequentlv  en- 
countered is  due  to  the  persistence  of  a  portion  of  the 
embryonic  pupillary  membrane,  which  has  adhered  to 
the  lens  capsule  and  undergone  calcification.  A  cir- 
cumscribed, densely  white  opacity,  occupying  a  limited 
portion  of  the  pupillary  area,  and  evidently  lying  upon, 


DISEASES    OF    THE    CRYSTALLINE    LENS.  32 1 

and  not  within,  the  capsule,  is  observed.     Vision  is  not 
necessarily  greatly  disturbed. 

The  other  variety  of  anterior  polar  cataract,  known 
also  as  pyramidal  cataract,  occasionally  develops  during 
intrauterine  life,  but  is  commonly  of  postnatal  origin, 
and  has  its  starting-point  in  a  central,  perforating  ulcer 
of  the  cornea,  usually  consequent  upon  ophthalmia  neo- 
natorum (Fig.  123).  When  a  perforation  of  the  cornea 
occurs,  the  aqueous  humor  escapes,  the  anterior  chamber 
is  obliterated,  and  the  iris  and  lens  are  pressed  forward 
so  that  they  lie  in  contact  with  the  cornea,  where  they 
remain  until  the  anterior  chamber  is  restored.     When 


Fig.  123. — Anterior  polar  cataract  (after  Xettleship). 

the  perforation  is  so  situated  that  the  lens  lies  in  direct 
contact  with  it,  an  irritation  results  which  leads  to 
proliferation  of  the  subcapsular  epithelial  cells.  The 
outcome  of  this  is  the  formation,  just  beneath  the  an- 
terior capsule,  of  a  sort  of  fibrous  tissue,  which  is  white 
and  opaque,  and  persists  throughout  life  (Fig.  124).  In 
addition  to  this,  there  is  frequently  a  projecting  mass  of 
opaque  material  upon  the  external  surfaceof  the  capsule, 
at  a  point  corresponding  with  the  intracapsular  opacity. 
This  consists  of  an  organized  exudate  which  remains 
adherent  to  the  capsule  when,  in  consequence  of  the 
re-accumulation   of  the   aqueous    humor,   the   lens   is 


322 


PREVALENT    DISEASES    OF    THE    EYE. 


pushed  away  from  the  cornea.  The  pyramidal  shape 
of  this  opacity  is  evidently  the  result  of  the  traction  to 
which  it  is  subjected  when  the  lens  and  cornea  are  thus 
forced  apart.  A  perceptible  corneal  opacity  usually 
marks  the  site  where  the  ulcer  perforated,  and  in  some 
instances  there  may  be  seen  a  slender  band  of  opaque 
tissue  connecting  this  opacity  with  the  apex  of  the 
epicapsular  exudate.  The  degree  of  visual  disturbance 
in  pyramidal  cataract  depends  largely  upon  the  size  of 


Fig.  124.— Section  of  anterior  polar  cataract.  Magnified  40  X  i  (Fuchs). 
The  capsular  cataract  forms  a  projection  upon  the  anterior  surface  of  the  lens, 
covered  by  the  capsule,  k,  which  is  unchanged  and  simply  thrown  into  folds. 
The  capsular  epithelium,  e,  loses  its  regularity  at  the  border  of  the  cataract, 
its  cells  being  increased  in  number  and  separated  by  the  cataract  from  the 
capsule,  so  as  to  form  for  a  short  distance  the  posterior  boundarj-  of  the  cat- 
aract. The  cataract  consists  of  a  fibrous  tissue,  with  cells  lying  in  the 
spindle-shaped  gaps  between  the  fibers.  Succeeding  the  cataract  posteriorly 
is  liquor  morgagni,  M,  which  is  coagulated  into  a  pulverulent  mass,  separat- 
ing the  capsule  from  the  cataractous  layers  of  the  lenticular  corte.x  (which 
are  not  represented  in  the  illustration). 

the  opacity  relatively  to  that  of  the  pupil,  and  upon  its 
sharpness  of  definition.  A  dense  opacity,  if  small  and 
defined,  is  not  incompatible  with  good  vision.  The 
corneal  scar,  though  much  less  conspicuous,  mav  pro- 
duce far  greater  disturbance  of  sight. 

Posterior  Polar  Cataract. — Opacities  at  the  posterior 

pole  of  the  lens,  which  are  apt  to  cause  greater  impair- 

I  ment  of  vision  than  those  at  the  anterior  pole,  can  seldom 

'  be   detected  without  the   aid   of  the  ophthalmoscope. 


DISEASES    OF    THE    CRYSTALLINE    LENS. 


323 


though  in  some  instances,  with  a  widely  dilated  pupil, 
they  may  be  fairly  well  seen  by  oblique  illumination. 
Observed  in  this  way,  they  are  rather  ill-defined  and 
of  a  yellowish-gray  color,  whereas  with  the  ophthalmo- 
scope they  appear  black  against  the  red  background 
of  the  eye. 

In  the  commoner  form  of  posterior  polar  cataract  the 
opacity,  which  may  lie  either  just  in  front  of  the  capsule 
or  between  it  and  the  hyaloid  fossa,  is  usually  diffuse 
and  ill-defined,  sometimes  exhibiting  an  imperfect  star- 


Fig.  125. — Posterior  polar  cat-  Fig.  126. — Cross-section  of  zonu- 

aract  as  seen  by  transmitted  light  lar  cataract.    Schematic.     Magni- 

(from  a  case  of  pigmentary  degen-  fied  2X1  (Fuchs).     The  layers,  s, 

eration  of  the  retina)  (Hopkins).  lying  between  nucleus  and  cortex, 

are  opaque,  but  the  adjacent  layer  is 
so  only  in  the  equatorial  region,  r, 
indicating  the  presence  of  "riders." 

shape  (Fig.  125).     This  variety  is  commonly  due  to  pre- 
existent  disease  of  the  deeper  tunics  of  the  eye,  which  has 
(  interfered  with  the  normal  nutrition  of  the  lens.     Ret- 
initis pigmentosa,  diffuse  choroido-retinitis,  and  myopia 
jof  high    grade,    attended    by  marked   choroido-retinal 
!  changes,  are  the  conditions  most  apt  to  give  rise  to  it. 
The  impairment  of  vision  is  apt  to  be  considerable, 
and  there  is  a  greater  probability  than  in  any  other  form 
of   partial   cataract    that  the  opacity    may    eventually 
involve  the  whole  lens. 


324  PREVALENT    DISEASES    OF    THE     EYE. 

1  lie  Other,  and  rarer,  form  of  posterior  polar  cataract 
is  of  congenital  origm,  and  is  due  to  the  incomplete 
disappearance  of  the  remains  of  the  hyaloid  arter)', 
which  in  fetal  life  runs  forward  in  the  vitreous  humor 
to  the  posterior  pole  of  the  lens.  The  opacity,  which 
is  upon,  not  within,  the  capsule,  is  small  and  defined, 
and  seldom  produces  an  appreciable  disturbance  of 
sight.  Occasionally  remnants  of  the  hyaloid  artery 
may  be  traced  from  the  epicapsular  opacity  to  the 
optic  disc. 

Zonular,  or  Lamellar,  Cataract. — This  is,  perhaps, 
the  most  peculiar  and  interesting  variety  of  partial  cat- 
aract. The  zone  of  opacity,  which  has  been  described 
(Fig.  126),  varies  considerably  in  size  and  also  in  thick- 
ness. Exceptionally  there  may  be  more  than  one 
opaque  zone,  the  smaller  zone  being  within  the  larger, 
and  separated  from  it  by  a  layer  of  transparent  lens  sub- 
stance. Under  such  circumstances  there  is  first  a  zone 
of  clear  lens  next  to  the  capsule,  then  an  opaque  zone, 
then  another  clear  zone,  and  within  this  a  second  opaque 
zone  enclosing  a  transparent  nucleus. 

This  singular  form  of  lens  opacity,  which  nearh- 
always  affects  both  eyes,  and  a  disposition  to  which  is 
not  infrequently  inherited,  develops  either  during  the 
last  months  of  fetal  life  or  in  early  infancy,  never  in 
adult  life.  It  is  often  found  in  association  with  inher- 
ited syphilis,  rickets,  or  scrofula,  and  the  majority  of 
individuals  in  whom  it  occurs  have  suffered  with  infan- 
tile convulsions.  Though  its  etiology  is  but  imperfectly 
understood,  it  is  probable  that  the  explanation  of  its  de- 
velopment is  to  be  found  in  faulty  nutrition,  perhaps  of 
intermittent  degrees  of  intensity.  Its  frequent  associa- 
tion with  rachitic  teeth  is  interesting,  and  helps  to 
throw  some  light  upon  the  way  in  which  it  is  produced. 


DISEASES    OF    THE    CRYSTALLINE    LENS.  325 

There  is  commonly  marked  impairment  of  sight, 
though  not  so  marked  as  in  advanced  general  cataract. 
The  amount  of  visual  disturbance  depends  upon  the 
thickness  and  density  of  the  opaque  zone,  and  there  are 
cases  in  which  this  thickness  and  density  are  so  slight 
as  to  interfere  but  little  with  vision.  In  most  instances 
the  opacity  remains  stationary,  and  retains  its  pecul- 
iarity, throughout  life,  though  exceptionally  the  whole 
lens  ultimately  may  become  opaque. 

The  true  character  of  zonular  cataract  seldom  can 
be  recognized  until  the  pupil  has  been  dilated  by  a 
mydriatic;  for  before  this  is  done  it  presents  much  the 
appearance  of  an  ordinary,  immature  cortical  cataract. 
With  the  pupil  widely  dilated,  however,  the  clear  per- 
ipheral zone  enclosing  the  smaller  opaque  zone  may 
be  made  out  easily  by  oblique  illumination  or  with  the 
ophthalmoscope  or,  as  has  been  suggested,  when  an 
ophthalmoscope  is  not  available,  with  the  ordinary  ear 
or  throat  mirror  (Plate  VIII,  Figs.  3  and  4). 

T^reatment  of  Partial  Cataract. — In  anterior  polar 
cataract,  unless  the  vision  is  decidedly  impaired,  no 
treatment  is  indicated.  If,  however,  the  opacity  is  so 
considerable  in  extent  as  to  occupy  the  greater  part  of 
the  pupillary  area,  an  iridectomy,  made  with  the  view 
of  obtaining  an  artificial  pupil  opposite  a  clear  portion 
of  the  lens,  may  be  of  decided  benefit.  The  instillation 
of  a  mydriatic  will  indicate  to  what  extent  vision  is 
likely  to  be  improved  by  this  procedure. 

In  posterior  polar  cataract  an  iridectomy  is  apt  to 
be  of  little  utility,  and,  as  a  rule,  operative  treatment  is 
not  indicated.  When,  however,  the  sight  of  both  eyes 
is  markedly  impaired  an  endeavor  to  cause  the  whole 
lens  to  become  opaque,  by  Forster's  method  or  possibly 
by  cautious  needling,  with  a  view  to  its  subsequent  re- 


326  PREVALENT    DISEASES    OF    THE     EYE. 

moval,  is  justifiable.  When  the  opacity  is  consequent 
upon  choroido-retinitis,  treatment  of  the  latter  condition 
is  called  for,  and  may  be  of  some  avail. 

Zonular  cataract,  if  it  causes,  as  it  usually  does, 
marked  impairment  of  sight,  should  be  dealt  with  in 
one  of  two  ways — either  an  artificial  pupil  should  be 
made  opposite  the  clear  portion  of  the  lens  or  discission 
should  be  performed.  The  former  procedure  is  indi- 
cated when  the  cloudy  zone  is  small  and  the  clear  zone 
relatively  broad  and  free  from  the  opaque  spokes 
("riders,"  as  they  have  been  called)  which  not  infre- 
quently are  present,  and  when,  moreover,  dilatation  of 
the  pupil  by  a  mydriatic  is  found  to  produce  decided 
improvement  in  vision.  Discission  is  called  for  when 
the  opposite  conditions  exist,  that  is,  when  the  opaque 
zone  is  wide,  the  clear  zone  narrow,  when  there  are  man\' 
and  conspicuous  "riders,"  and  when  inconsiderable  im- 
provement in  sight  results  from  mvdriasis.  The  process 
of  absorption  of  the  lens  through  needling  is  a  slow  one 
in  zonular  cataract  because  so  much  of  the  lens  is  clear, 
and  the  breaking  down  of  its  fibers,  which  must  precede 
their  solution  and  absorption,  takes  a  long  time;  but  the 
ultimate  result  is  apt  to  be  more  satisfactory  than  when 
an  artificial  pupil  is  made.  After  the  lens  has  been  ab- 
sorbed a  cataract  glass  must,  of  course,  be  worn. 

Secondary,  or  Capsular,  Cataract. — After  operations 
upon  the  lens  and  after  injuries  involving  the  integrity  of 
its  capsule  it  may  happen  that  some  of  the  lens  substance 
becomes  imprisoned  within  the  capsule  in  such  a  man- 
ner as  to  resist  absorption.  It  ma^■  also  happen  that 
inflammatorv  exudates  are  deposited  upon  or  within 
the  torn  capsule.  In  either  case  a  more  or  less  pro- 
nounced opacity,  occupying  the  pupillarv  area  and  ser- 
iously interfering  with  vision,  ma)-  result.     Such  opaci- 


DISEASES    OF    THE    CRYSTALLINE    LENS.  327 

ties  are  called  secondary  or  capsular  cataracts,  and,  if 
the  disturbance  of  vision  which  they  cause  is  consider- 
able, must  be  dealt  with  by  operative  procedure. 

Capsular  cataracts  are  often  so  conspicuous  that 
they  may  be  detected  at  a  glance;  but  they  can  be  ex- 
amined best,  and  their  extent  and  character  determined 
most  satisfactorily,  by  oblique  illumination,  after  the 
pupil  has  been  widely  dilated  by  a  mydriatic. 

Treat77ie77t. — This  consists  in  making  a  rent  in  the 
opaque  membrane— in  its  center,  if  possible — so  that 
a  clear  area  may  be  secured  through  which  light  can 
pass,  unobstructed,  to  the  retina.  Exceptionally,  it 
may  be  necessary  to  deal  with  these  secondary  opacities 
in  a  more  radical  way;  but  usually  the  desired  result 
may  be  attained  by  a  discission  operation,  that  is,  by 
introducing  a  cataract  needle  or  needle-knife  into  the 
anterior  chamber  through  the  cornea,  near  its  periphery, 
and  cutting  or  tearing  (for  it  is  oftener  a  tear  rather  than 
a  cut^  the  authorities  to  the  contrary,  notwithstanding) 
an  opening  in  the  opaque  membrane.  If  the  membrane 
is  thick,  it  is  best  to  divide  it  crucially;  but  when,  as  is 
often  the  case,  it  is  cobweb-like  in  character,  a  linear 
incision  suffices,  as  the  elasticity  of  the  capsule  causes 
the  rent  to  expand  sufficiently  for  the  end  in  view.  The 
operation  is  done  under  cocain,  with  the  strictest  anti- 
septic precautions,  and  with  the  pupil  dilated  ad  max- 
imum. 

Dislocation  of  the  Crystalline  Lens  (Luxation  of 
the  Lens). — Dislocation  of  the  crystalline  lens,  which 
occurs  as  a  congenital  as  well  as  an  acquired  condition, 
may  be  complete  or  incomplete,  and  the  displacement 
may  be  forward,  into  the  anterior  chamber,  or  back- 
ward, into  the  vitreous  chamber.  The  lens  is  said  to  be 
incompletely  dislocated  when  it  remains  in  the  hyaloid 


328 


PREVALENT    DISEASES    OF    THE     EYE. 


fossa,  held  measurably  in  place  by  remnants  of  the 
suspensory  ligament  or  by  the  support  of  the  vitreous 
humor.  It  is  said  to  be  completely  dislocated  when  it 
has  fallen  back  into  the  vitreous  chamber  or  has  passed 
through  the  pupil  into  the  anterior  chamber. 

Congenital  dislocation  of  the  lens,  which  is  commonly 
bilateral  (Fig.  127),  and  to  which  there  is  not  infre- 
quently an  inherited  disposition,  is  usually  incomplete, 
and  is  due  to  imperfect  development  or  absence  of  the 
zonule  of  Zinn.  Acquired  dislocation  is  commonly  the 
result  of  traumatism,  though  in  certain  conditions  of  the 


Fig.  127. — Congenital  dislocation  of  the  crystalline  lenses,  up  and  out  (de 

Schweinitz). 


eye — myopia  of  high  grade,  especially,  or  after  chronic 
inflammation  of  the  uveal  coat — a  very  trivial  accident, 
an  inconsiderable  blow  upon  the  eye,  for  example,  may 
suffice  to  bring  it  about.  Dislocation  of  the  lens  be- 
neath the  conjunctiva  (Fig.  128)  is  occasionally  observed 
in  severe  injuries  of  the  eye  involving  rupture  of  the 
sclera  near  the  corneal  border. 

Displacement  of  the  lens  from  behind  the  pupil,  un- 
less it  happens  to  occur  in  a  very  myopic  eye,  necessarily 
causes  marked  impairment  of  vision.  Moreover,  by 
acting  as  a  foreign  body,  the  lens  when  loose  in  the 
vitreous  chamber,  and  this  is  still  more  apt  to  happen 


DISEASES    OF    THE    CRYSTALLINE    LENS.  329 

when  it  is  lodged  in  the  anterior  chamber,  may  cause 
great  irritation,  and  excite  severe  inflammatory  reac- 
tion. 

The  disturbance  ot  vision  from  a  partially  dislocated 
lens,  if  the  margin  of  the  lens  happens  to  be  in  line 
with  the  pupil,  is  especially  annoying;  tor  under  such 
circumstances  two  images  are  formed  upon  the  ret-/ 
ina,  a  more  distinct  one  by  the  rays  of  light  which  pass 
through  the  lens,  and  a  less  distinct  one  by  those  which 
reach  the  retina  without  passing  through  it,  monocular 
diplopia  being  the  result.  A  partially  dislocated  lens 
which  lies  behind  the  pupil  in  a  tilted  position — a  con- 


Fig.  12S. — Subconjunclivai  dislocation  of  lens  (Haab). 

dition  not  infrequently  observed — also  causes  marked 
impairment  of  sight,  since  it  necessarily  produces  a 
high  degree  of  astigmatism. 

A  case  of  complete,  probably  congenital,  dislocation 
of  both  lenses,  exhibiting  very  unusual  and  interesting 
features,  was  observed,  and  an  account  of  it  published, 
by  the  author  some  vears  since*:  In  each  eye  of  a  lad, 
twelve  years  of  age,  the  lens  was  completely  dislocated 
into  the  vitreous  chamber.     In  spite  of  this  fact,  and 

*  "Report  of  a  case  in  which  useful  vision  was  maintained  through 
a  number  of  years  by  the  aid  of  a  totally  dislocated  lens."  Trans, 
of  the  American  Ophthalmological  Society,  1881.  With  supple- 
mentary notes,  as  to  the  later  history  of  the  case,  in  the  Transactions 
of  the  Society  for  1891  and  1893. 


330  PREVALENT    DISEASES    OF    THE     EYE. 

though  he  had  never  had  compensating  glasses,  he  had 
attended  school,  had  been  able  to  keep  up  with  his 
classes,  and  had  been  much  given  to  reading  for 
pleasure. 

In  the  course  of  my  examination  of  the  case  it  de- 
veloped that  his  ability  to  read  was  due  to  his  having 
acquired  the  knack  of  using  one  of  the  dislocated  lenses. 
Without,  of  course,  appreciating  the  significance  of  the 
maneuver,  he  was  in  the  habit,  whenever  he  wanted  to 
see  any  small  object,  as  in  reading,  of  bending  his  head 
forward,  with  face  to  the  ground.  This  brought  the 
lens  into  position  behind  the  pupil  (as  I  satisfied  myself 
by  observation  with  the  ophthalmoscope),  and  in  this 
awkward  fashion  he  was  able  to  read  with  ease  the  finest 
print.  He  was  given  far  and  near  glasses,  which  greatly 
improved  his  distant  vision,  and  enabled  him  to  read 
with  his  head  in  a  natural  position.  Ten  years  sub- 
sequently, when  he  was  twenty-two  years  of  age,  the 
capsule  of  the  lens  in  the  left  eye  ruptured.  This  was 
followed  by  considerable  inflammatory  reaction  and 
decided  impairment  of  vision.  However,  the  lens  grad- 
ually underwent  absorption,  though  a  fragment  of  the 
nucleus  proved  very  obdurate,  the  inflammatory  symp- 
toms subsided,  and  vision  regained  its  former  standard. 
Six  years  after  this  the  same  thing  happened  to  the 
right  eye,  and  for  a  time  there  was  the  same  decided 
inflammatory  reaction,  which  was  not  without  difiicultv 
gotten  under  control. 

Partial  or  complete  dislocation  of  the  lens  backward 
is  not  always  easy  of  detection.  A  completely  dislo- 
cated lens — one  that  has  fallen  into  the  vitreous  chamber 
—can  be  seen  only  with  the  help  of  the  ophthalmoscope; 
a  partially  dislocated  lens,  after  the  pupil  has  been 
dilated  by  a  mydriatic,  may  be  satisfactorily  inspected, 


DISEASES    OF    THE    CRYSTALLINE    LENS.  33I 

and  its  position  determined,  by  oblique  illumination. 
A  nearly  constant  symptom  of  backward  dislocation  of 
the  lens  is  tremulousness  of  the  iris — iridodonesis. 
This  results  from  the  iris  having  lost  the  support  which 
the  lens  under  normal  conditions  affords  it.  The  exist- 
ence of  this  symptom,  therefore,  should  always  raise 
a  suspicion  that  the  lens  is  more  or  less  completely 
luxated. 

When  the  lens  lies  in  the  anterior  chamber  (Fig.  129) 
the  ease  with  which  it  may  be  detected  by  the  non-expert 
depends  largely  upon  whether  it  is  transparent  or  catar- 


'^^^tH^-^^^ 


Fig.  129. — Dislocation  of  lens  into  anterior  chamber  (Hansell  and  Sweet). 

actous — for,  it  should  be  stated,  dislocated  lenses  are 
very  apt  in  time  to  become  cataractous.  An  opaque 
lens  in  this  situation  should  be  detected  at  a  glance,  and 
the  true  state  of  affairs  easily  recognized.  On  the 
other  hand,  when  the  lens  is  clear  it  is  not  so  easy  as 
might  be  supposed  to  make  a  correct  diagnosis.  Oblique 
illumination  would  afford  assistance,  and  a  significant 
feature  would  be  the  unusual  depth  of  the  anterior 
chamber.  In  some  instances  a  dislocated  lens  has  a 
habit  of  gliding  through  the  pupil,  and  being  found  now 
in  front,  and  now  behind,  the  iris. 

Treatment. — When  a  dislocated  lens  lies  in  the  an- 


332  PREVALENT    DISEASFS    OF    THE     EYE. 

terior  chamber  it  is  almost  sure  to  give  rise  to  much 
irritation,  and  to  excite  inflammation,  it  may  be  of  a 
glaucomatous  character.  Its  removal,  therefore,  is 
indicated.  The  operation  is  a  delicate  one,  more  so 
than  an  ordinary  extraction  of  cataract,  and  should  be 
undertaken  only  by  one  skilled  in  the  performance  of 
ophthalmic  operations. 

A  partially  dislocated  lens  may  or  may  not  require 
radical  treatment.  If  it  causes  but  little  impairment 
of  sight  it  should  be  left  undisturbed,  glasses  being  given 
if  found  to  be  of  assistance;  but  if  it  is  so  placed  as  to 
interfere  seriously  with  vision  it  may  be  extracted  or, 
perhaps,  needled,  the  latter  procedure  being  indicated 
only  in  young  subjects.  The  extraction  of  a  displaced 
lens  which  has  not  left  the  hyaloid  fossa,  and  is  supported 
by  a  vitreous  humor  of  normal  consistency,  is  hardly 
more  difficult  than  the  ordinary  removal  of  a  cataract. 

A  lens  completely  dislocated  into  the  vitreous  cham- 
ber should  not  be  disturbed,  unless  it  is  causing  serious 
inflammatory  reaction;  for  under  such  circumstances 
the  vitreous  humor  is  apt  to  be  in  a  fluid  or  semifluid 
state,  and  an  attempt  to  remove  the  lens  is  a  hazardous 
procedure.  It  is  possible,  with  the  help  of  the  ophthal- 
moscope, to  needle  a  lens  so  situated,  the  needle  being 
introduced  through  the  sclera,  and  this  procedure  might 
be  justifiable  in  a  young  person.  Another  possible  pro- 
cedure is  to  coax  the  lens  by  suitable  manipulation 
through  a  dilated  pupil  into  the  anterior  chamber,  and, 
after  imprisoning  it  there  by  the  use  of  a  strong  myotic, 
to  extract  it  through  a  corneal  section 

A  lens  dislocated  beneath  the  conjunctiva  may  be 
extracted  without  difficulty.  After  the  removal  of  a 
dislocated  lens  glasses,  such  as  are  prescribed  after  an 
operation  for  cataract,  are,  of  course,  necessary. 


DISEASES    OF    THE    VITREOUS    HUMOR. 


333 


DISEASES  OF  THE  VITREOUS  HUMOR. 

Pathological  changes  in  the  vitreous  humor  seldom 
occur  except  as  a  resuh  ot  traumatic  lesions  of  the  eye 
or  in  consequence  of  disease  of  the  uveal  coat  or  retina. 

Purulent  Panophthalmitis. — The  vitreous  humor 
affords  an  excellent  medium  for  the  grow^th  of  bac- 
teria, and  when   a  pyogenic  organism  finds  lodgment 


Fig.  130. — Panophthalmitis,  from  entrance  of  a  piece  of  iron  into  the  vitreous 
chamber  (Haab). 


there,  as  a  result  of  a  penetrating  wound  of  the  eye, 
operative  or  accidental,  a  destructive  and  usually  uncon- 
trollable suppurative  panophthalmitis  is  apt  to  ensue 
(Fig.  130).  Under  such  circumstances,  in  a  very  brief 
time,  purulent  infiltration  of  the  entire  vitreous  body 
occurs;  the  uveal  coat  and  cornea  are  soon  involved; 
and  after  much  suffering,  attended  by  marked  chemosis 
of  the  conjunctiva  and  great  tumefaction  of  the  lids, 
necrosis  of  the  cornea  or  of  the  sclera  at  some  point 


334  PREVALENT    DISEASES    OF    THE     EYE. 

takes  place.  Then  there  is  an  escape  of  pus,  with  con- 
sequent reduction  of  the  intraocular  tension,  and  a 
measurable  relief  from  pain  is  experienced.  Complete 
loss  of  sight  always  results,  and  ultimately  atrophy  of 
the  eyeball. 

Treattnent. — So  far  as  arrest  of  the  suppurative  pro- 
cess and  preservation  of  sight  are  concerned,  treatment 
is  seldom  of  avail.  Anodynes  are  indicated  to  control 
the  pain,  and  hot  fomentations — the  lotion  of  opium, 
made  stronger  than  is  commonly  necessary  (ext.  opii, 
gr.  XV ;  aquae,  5iv) — afford  some  relief.  When  it  is 
evident  that  there  is  no  hope  of  preserving  sight,  the 
eye  should  be  enucleated  without  unnecessary  delay. 
The  danger  of  cerebral  or  systemic  infection  from  the 
performance  of  the  operation  while  the  inflammation 
is  still  active  seems  to  the  author  to  have  been  much 
exaggerated,  and  the  relief  from  suffering  which  it  af- 
fords is  almost  instantaneous. 

Fluidity  of  the  Vitreous  Humor  (Synchysis). 
— This  condition  usually  results  from  chronic  in- 
flammation of  the  uveal  coat.  It  is,  perhaps,  often- 
est  met  with  in  myopia  of  high  grade  attended  by 
marked  choroido-retinal  changes.  It  is  the  outcome 
of  malnutrition,  and  is  frequently  accompanied  by 
floating  opacities.  The  loss  of  consistency  is  seldom 
complete,  though  cases  of  this  character  are  encoun- 
tered. Fluidity  of  the  vitreous  body  does  not  in  itself 
cause  inconvenience;  but  it  probably  predisposes  to 
detachment  of  the  retina,  being  usually  attended  by 
subnormal  intraocular  tension,  and  it  may  lead  to  com- 
plications in  operations,  such  as  extraction  of  cataract, 
or  wounds  which  involve  penetration  of  the  coats  of  the 
eye.     Treatment  is  ineffectual. 

Opacities  of  the  Vitreous  Humor. — The  vitreous 


DISEASES    OF    THE    VITREOUS    HUMOR.  335 

humor  may  be  diffusely  clouded,  or  it  may  con- 
tain discrete  opacities,  varying  greatly  in  size  and  num- 
ber. Inflammation  of  the  uveal  coat,  at  all  severe,  is 
commonly  attended  by  more  or  less  marked  loss  of 
transparency  of  the  vitreous  body.  At  first  the  opacity 
is  apt  to  be  diffuse;  but  at  a  later  stage,  instead  of  a 
uniform  cloudiness,  we  have  ragged  masses  or  shreds, 
resembling  bits  of  cobweb,  which  float  about  freely, 
indicating,  at  least,  partial  synchysis.  In  time,  and 
when  the  conditions  are  favorable,  an  opacity  so  dense 
as  not  only  to  preclude  a  view  of  the  background  of  the 
eye  with  the  ophthalmoscope,  but  to  do  away  with  all 
fundus  reflex,  and  to  reduce  vision  to  mere  light  per- 
ception, may  disappear  completely,  leaving  no  trace 
which  the  ophthalmoscope  can  discover.  Discrete 
opacities,  which  seldom  are  stationary,  but  float  about 
w^ith  considerable  freedom,  often  cause  much  annoy- 
ance by  obstructing  the  view  especially  of  small  objects 
through  interference  with  the  rays  of  light  in  their  pas- 
sage to  the  fundus  of  the  eye,  and  by  casting  shadows 
upon  the  retina. 

"Vitreous  opacities"  of  considerable  size  can  be 
detected  easily  with  the  ophthalmoscope,  and  their 
movements  and  position  in  the  posterior  chamber  of  the 
eye  determined.  Opacities  too  small  to  be  seen  in  this 
way  are  not  of  moment,  and  yet  such  microscopic  opac- 
ities, known  as  nniscce  vohtantes,  w^hich  exist  in  all 
eyes,  and  under  certain  conditions,  as  when  one  looks 
toward  a  white  wall  or  a  light  cloud,  can  always  be 
perceived  by  the  individual,  give  rise  to  much  uncalled- 
for  anxiety.  There  is  a  wide-spread  popular  belief, 
often  difficult  to  combat,  that  the  presence  of  "muscae" 
is  indicative  of  impending  blindness — of  the  develop- 
ment of  cataract  or  what  not.     It  is  undoubtedly  true 


^^6  PREVALENT    DISEASES    OF    THE     EYE. 

that  they  are  more  numerous  and  more  conspicuous  in 
eyes  made  irritable  by  refractive  or  muscular  anomalies, 
and  to  this  extent  they  are  significant;  but  the  dread 
which  they  so  often  inspire  is  entirely  unwarranted. 

Hemorrhages  into  the  vitreous  humor  which  have 
undergone  but  partial  absorption  may  give  rise  to  large 
floating  opacities,  and  opacities  which  are  composed  of 
an  organized  inflammatory  exudate,  accompanied  by 
new-formed  blood-vessels,  and  which  shoot  out  into 
the  vitreous  humor  from  the  retina,  are  observed  in 
certain  types  of  retinitis. 

Treatmeytt. — The  treatment  of  opacities  of  the  vit- 
reous humor  is  the  treatment  of  the  condition  or  con- 
ditions upon  which  they  depend.  The  major  opacities, 
as  has  been  stated,  are  usually  caused  by  inflammation 
of  the  uveal  coat,  and  this  must  be  combated  by  the 
means  described  in  the  chapters  in  which  diseases  of 
the  ins  and  ciliary  bod\'  and  of  the  choroid  coat  are  dis- 
cussed. The  minor  opacities  (muscae),  when  con- 
spicuous, suggest,  as  has  just  been  intimated,  accommo- 
dative or  muscular  strain,  and  their  existence  should 
lead  to  a  careful  search  for  optical  and  muscular  faults, 
and  to  an  equally  careful  correction  of  these,  by  glasses 
or  by  operation,  should  they  prove  to  be  present.  The 
lotion  of  opium,  by  lessening  the  irritability  of  the  eves, 
will  also  be  found  useful. 

Hemorrhage  into  the  vitreous  humor  occurs  as 
a  result  of  injuries  of  the  eye,  of  disease  of  the 
choroid  coat  or  retina,  or  in  consequence  of  angioscle- 
rosis  or  of  alterations  in  the  composition  of  the  blood. 
It  takes  place  usually  from  the  vessels  of  the  choroid, 
less  often  from  those  of  the  ciliary  body  or  retina.  It 
has  been  observed  at  times  in  association  with  frequent 
attacks  of  epistaxis,  also,  in  recurrent  form,  in  connec- 


DISEASES    OF    THE    VITREOUS    HUMOR.  ^^J 

tion  with  delayed  menstruation.  When  the  extravasa- 
tion is  considerajple,  vision  may  be  reduced  to  Hght  per- 
ception, and  the  ophthahnoscope  may  give  only  a  black 
or  reddish-black  reflex.  In  some  instances  the  blood 
is  evenly  diffused  throughout  the  vitreous  body,  and 
then  objects,  which  are  seen  indistinctly,  have  a  reddish 
color,  and  the  fundus  of  the  eye  is  seen  with  the  ophthal- 
moscope as  through  a  red  mist.  Oftener  it  is  in  ill- 
defined,  opaque  masses,  which,  according  to  their  po- 
sition, may  or  may  not  prevent  a  view  of  the  optic  disc 
and  neighboring  parts. 

The  absorption  of  the  blood  from  the  vitreous  cham- 
ber is  much  more  tedious  than  from  the  aqueous  cham- 
ber, and  is  not  so  surely  complete,  floating  opacities, 
as  has  been  stated,  being  left  in  the  vitreous  humor, 
not  infrequently,  as  the  result  of  its  incomplete  disap- 
pearance. In  cases  of  recurrent  hemorrhage  sight  is  apt 
to  suffer  serious  and  permanent  injury;  but  usually  after 
a  single  hemorrhage,  when  finally  the  extravasated  blood 
has  disappeared,  vision  regains  its  former  standard. 

Treatment. — Rest  of  the  eyes  and  avoidance  of  active 
exercise,  for  a  time  at  least,  are  indicated.  Ergot  is 
supposed  to  lessen  the  likelihood  of  a  recurrence  of  the 
hemorrhage;  but  adrenalin,  it  would  seem,  should  be 
still  more  efficacious.  Habitual  constipation,  if  present, 
should  be  corrected,  aloin,  in  such  doses  as  may  be 
found  necessary,  being  especially  useful  for  this  pur- 
pose. Potassium  iodid  should  be  given  in  five-  to  ten- 
grain  doses,  as  it  unquestionably  promotes  the  absorp- 
tion of  extravasated  blood  from  the  vitreous,  as  well  as 
from  the  aqueous,  chamber.  Local  remedies  are  of 
but  little  value;  though,  when  the  absorption  of  the 
hemorrhage  is  tardy,  subconjunctival  injections  of  salt 
solution  are  serviceable. 


CHAPTER  X. 

DISEASES  OF  THE  CHOROID  COAT,  RETINA,  AND 
OPTIC  NERVE. 

Although,  without  the  help  of  the  ophthalmoscope, 
it  is  impossible  to  diagnosticate  with  accuracy,  and  for 
this  reason  to  treat  intelligently,  the  several  affections  to 
be  considered  in  this  chapter,  the  physician  who  is  not 
an  ophthalmoscopist  need  not  be  wholly  at  a  loss  in 
dealing  with  these  diseases  of  the  deeper  eye  structures; 
for  they  are  commonly  attended  by  certain  objective 
and  subjective  symptoms  which  are  fairly  pathogno- 
monic, and  which  when  taken  into  account  permit,  at 
least,  of  approximate  accuracy  in  diagnosis. 

As  a  rule,  it  may  be  stated,  no  external  signs  of  in- 
flammation are  observable  in  choroiditis,  in  retinitis, 
or  in  optic  neuritis.  Nor  are  these  afi^ections  commonly 
accompanied  by  ocular  pain,  or  by  photophobia,  or 
lacrimation.  Obscuration,  more  or  less  marked,  of 
both  distant  and  near  vision  is  the  most  constant  and 
conspicuous  subjective  symptom,  while  enlargement  of 
the  pupil  and  sluggishness  in  its  response  to  light  are  the 
chief  objective  symptoms.  Exceptionally,  as  in  intra- 
ocular neuritis,  or  choked  disc,  and  in  diseases  affecting 
chiefly  the  periphery  of  the  choroid  or  retina,  very  good 
central  vision  may  exist  in  spite  of  the  fact  that  pro- 
nounced changes  observable  with  the  ophthalmoscope 
are  present;  and  in  inflammation  of  the  choroid,  if  the 
ciliary  body  be  involved,  there  will  almost  surely  be 
present  pericorneal  injection,  pain,  photophobia,  sensi- 

338 


CHOROID,    RETINA,    OPTIC    NERVE.  339 

tiveness  of  the  eyeball  to  pressure,  etc.  But  these  are 
the  exceptions  which  lend  force  to  the  rule  that  has  been 
enunciated,  and,  speaking  broadly,  it  may  be  said  that 
disease  of  the  optic  nerve  or  retina,  or  of  the  choroid  and 
retina  (for  the  retina  seldom  escapes  involvement  when 
there  is  considerable  inflammation  of  the  choroid),  is  to 
be  suspected  when  the  pupil  is  enlarged  and  responds 
imperfectly  to  light,  and  when,  glaucoma  having  been 
excluded,  distant  as  well  as  near  vision  is  impaired,  and 
is  growing  progressively  worse. 

It  should  be  borne  in  mind,  moreover,  in  endeavoring 
to  reach  a  diagnosis,  that  the  affections  under  considera- 
tion, though  encountered  in  infancy  and  childhood, 
are  more  common  in  middle  and  advanced  life;  that 
they  are  usually  binocular;  that  they  are  generally  due 
to  some  constitutional  disorder,  such  as  syphilis,  neph- 
ritis, diabetes,  angiosclerosis,  etc.;  that  they  may  occur 
during  the  course  of  the  exanthematous  fevers  or  as  a 
complication  in  pregnancy;  and  as  to  optic  neuritis  that 
it  is  very  commonly  the  result  of  coarse  intracranial 
disease.  However,  it  goes  without  saying  that  in  these 
grave  aflPections  the  physician  should  not  rest  content 
with  a  supposititious  diagnosis,  but  that  he  should  call 
to  his  aid  a  competent  ophthalmoscopist,  so  that  all 
uncertainty  as  to  what  is  the  true  condition  may  be 
dispelled. 

The  treatment  of  these  deeper  diseases  of  the  eye, 
local  measures  being  of  but  little  value,  is  mainly  con- 
stitutional, and  should  be  directed  to  the  underlying  sys- 
temic disorder  upon  which  they  depend.  The  prog- 
nosis, so  far  as  sight  is  concerned,  depends  largely  upon 
whether  this  underlying  malady  is  or  is  not  remediable. 
As  a  rule,  those  affections  that  are  of  syphilitic  origin 
are  the  most  amenable  to  treatment;  while,  as  might  be 


340  PREVALENT    DISEASES    OF    THE     EYE. 

supposed,  the  prognosis  is  least  favorable  in  those  due 
to  diabetes,  to  nephritis,  to  degenerative  changes  in  the 
vessel  walls,  and  to  non-luetic  intracranial  disease. 


DISEASES  OF  THE  CHOROID  COAT. 

Choroiditis,  or  inflammation  of  the  choroid  coat, 
occurs  as  a  purulent,  as  a  serous,  and  as  a  plastic  process. 
Purulent  choroiditis  is  but  another  name  for  purulent 
panophthalmitis,  which  has  been  considered  in  the  pre- 
ceeding  chapter,  while  serous  choroiditis,  which  is 
synonymous  with  serous  uveitis,  has  been  treated  of  in 
connection  with  diseases  ot  the  iris. 

Plastic  Choroiditis. — This  is  the  more  common 
variety  of  choroidal  inflammation,  and  is  oftenest  due 
to  syphilis,  inherited  or  acquired.  It  is  also  frequently 
present  in  progressive  myopia,  and  is  not  rarely  a  result 
of  traumatism. 

Syphilitic  inflammation  of  the  choroid  occurs  usually 
in  association  with  iritis  and  cyclitis,  but  well-marked 
cases  of  choroiditis  are  encountered  in  which  neither 
the  iris  nor  the  ciliarv  body  is  involved;  while  in  some 
instances,  reversing  the  usual  order,  the  inflammation 
begins  in  the  choroid  and  extends  from  there  to  the  cil- 
iary body  and  iris.  It  occurs  oftenest  in  the  secondary 
stage  of  the  disease,  but  may  manifest  itself  at  a  later 
period.  In  every  pronounced  case  of  luetic  choroiditis 
the  retina  is  invariably  implicated,  and,  if  the  macular 
region  is  involved  in  one  of  the  areas  of  more  intense 
inflammation  which  are  characteristic  of  the  disease, 
decided  and  permanent  impairment  of  vision  usually 
results.  On  the  other  hand,  if  this  region  is  not  seri- 
ously involved,  there  may  be  but  little  permanent  dam- 
age to  sight,  though  for  a  time  it  may  be  reduced  to  mere 


DISEASES    OF    THE    CHOROID    COAT. 


341 


light  perception,  owing  largely  to  opacity  of  the  vitreous 
humor. 

Loss  of  transparency  of  the  vitreous  humor  is  a  usual 
feature  of  syphilitic  choroiditis.  At  first  the  opacity  is 
diffuse,  and  often  so  dense  as  to  render  a  view  of  the 
background  of  the  eye  with  the  ophthalmoscope  im- 
possible. At  a  later  stage,  instead  of  this  uniform 
clouding,  we  have  ragged,  cobweb-like  opacities,  which 
float  more  or  less  freely  in  the  relatively  clear  vitreous 


Fig.  131. — Fundus  changes  consequent  upon  severe  (probably  syphilitic) 
choroiditis,  as  seen  with  the  ophthalmoscope  (de  Wecker). 


body,  and  impair  sight  to  a  greater  or  less  extent  ac- 
cording to  their  position  with  reference  to  the  visual 
axis.  Ultimately  these  floating  opacities  usually  dis- 
appear, and  with  their  disappearance  excellent  vision 
may  be  regained,  provided  the  retina,  its  central  portion 
more  especially,  has  not  suffered  serious  damage  (Fig. 

131)- 
The  disease  runs  a  tedious  course,  a  course  of  months 

rather  than   weeks,    and    is   apt   to   attack   both    eyes, 

though  energetic  treatment  not  infrequently  prevents 


342  PREVALENT    DISEASES    OF    THE     EYE. 

involvement  of  the  second  eye.  Its  existence  should  be 
suspected  whenever,  especially  during  the  secondary 
stage  of  syphilis,  marked  impairment  of  vision,  unat- 
tended by  pain  or  injection  of  the  eye,  occurs.  The 
presence  of  pain  and  circumcorneal  injection  indicates, 
as  has  been  pointed  out,  that  the  iris  and  ciliary  body 
are  involved  in  the  inflammatory  process. 

In  the  subjects  of  inherited  syphilis  plastic  choroiditis 
occurs  most  frequently  in  association  with  interstitial 
keratitis,  and  under  such  circumstances  iritis  also  is 
often  present.  It  may  make  its  appearance  at  any 
period  of  life,  even  as  a  prenatal  affection;  but,  like  inter- 
stitial keratitis,  it  is  encountered  oftenest  between  the 
ages  of  six  and  fifteen  or  sixteen  years.  The  prognosis 
is  unfavorable;  but  much  may  be  accomplished  by 
promptly  instituted  treatment.  Opacity  of  the  lens  is 
a  not  uncommon  consequence  of  unchecked  syphilitic 
choroiditis. 

The  choroiditis  of  myopia  of  high  grade  is  less  in- 
tense than  the  syphilitic  type;  but  as  it  occurs  at  the 
posterior  pole  of  the  eye  and  frequently  involves  the 
macular  region,  and  as  the  retina  is  always  implicated, 
the  consequences  to  vision  are  often  disastrous  (Fig. 
132).  Floating  vitreous  opacities,  large  enough  to  cause 
considerable  annoyance,  are  usually  present,  and  de- 
tachment of  the  retina,  and  the  development  of  cataract 
from  disturbance  of  the  nutrition  of  the  lens,  are  com- 
plications to  be  apprehended. 

Plastic  choroiditis  of  traumatic  origin,  with  which 
iritis  and  cyclitis  are  often  associated,  arises  most  fre- 
quently from  penetrating  wounds  of  the  eye  complicated 
by  hernia  of  some  portion  of  the  uveal  coat.  The  lodg- 
ment of  a  foreign  body  in  the  eye  is  especially  apt  to  give 
rise  to  it.     When   such   injuries   are   attended   by  the 


DISEASES    OF    THE    CHOROID    COAT. 


343 


entrance  of  a  pyogenic  micro-organism  into  the  interior 
of  the  eye  a  purulent  panophthalmitis  is  apt  to  super- 
vene; but  when  this  is  not  the  case  a  less  intense  inflam- 
mation, of  plastic  character,  usually  results.  The 
prognosis  in  these  cases  is  distinctly  unfavorable,  and 
enucleation  of  the  eye  is  often  demanded  to  prevent 
sympathetic  implication  of  the  fellow-eye. 

Miliary  Choroido-retinitis . — As  a  result    of    accom- 


Fig.  132. — Eye-ground  in  progressive  myopia.  Large  posterior  staphy- 
loma surrounding  the  nerve-head.  Macular  region  occupied  by  an  area  of 
semi-atrophic  choroido-retinitis  (de  Schweinitz). 


modative  strain,  especially  in  astigmatic  eyes  which 
without  glasses  or  with  improperly  adjusted  glasses 
are  much  taxed  in  reading,  writing,  etc.,  a  low  grade 
of  choroiditis,  or  rather  choroido-retinitis,  is  of  very 
common  occurrence;  and  because  of  the  frequency  of 
its  occurrence,  and  the  serious  consequences,  near  and 
remote,  to  which  it  gives  rise,  this  affection  deserves  fuller 
consideration  than  is  commonly   accorded   it  in  text- 


344  PREVALENT    DISEASES    OF    THE     EYE. 

books  upon  eye  diseases.  In  treating  of  the  etiology 
of  glaucoma  and  of  cataract  the  significance  of  this 
condition  has  already  been  emphasized. 

Unlike  the  severer  types  of  choroiditis  which  have 
been  described,  this  affection,  in  its  early  stages  at  all 
events,  is  not  attended  by  marked  impairment  of  sight. 
Instead,  we  have  irritability  of  the  eyes,  photophobia, 
easily  provoked  lacrimation  and  conjunctival  hyper- 
emia, and,  not  infrequently,  blepharitis  marginalis  and 
frontal  headache — in  a  word,  we  have,  in  intensified 
form,  the  complex  of  symptoms  which  constitutes  asthen- 
opia. At  first  the  ophthalmoscope  shows  a  markedly 
hyperemic  disc  and,  especially  in  the  neighborhood  of 
the  disc  and  the  macula,  an  undue  retinal  reflex,  indic- 
ative of  edema  of  the  retina.  After  a  time  this  retinal 
edema  disappears,  and,  instead,  we  find,  and  again 
most  marked  in  the  region  of  the  macula  and  between 
it  and  the  disc,  miliary  changes  in  the  choroido-retinal 
pigment — an  appearance  as  though  fine  black  pepper 
had  been  dusted  over  the  background  of  the  eye.  (See 
Frontispiece.)  In  after  years,  when  possibly  incipient 
cataracts  or  the  premonitory  symptoms  of  glaucoma  are 
manifesting  themselves,  there  is  observed  a  general 
thinning  of  the  pigment  of  the  choroid  and  retina,  show- 
ing too  plainly  the  choroidal  vessels,  with  the  islands  of 
pigment  between  them — the  so-called  "patchy"  cho- 
roid with  which  every  ophthalmoscopist  is  familiar. 

The  frequency  with  which  this  state  of  the  choroid, 
indicative,  as  I  believe  it  is,  of  a  precedent  "miliary" 
choroido-retinitis,  is  found  in  cataractous  and  in  glau- 
comatous eves  must  have  attracted  the  attention  of 
every  one  who  has  carefully  studied  such  eyes.  To  my 
mind  it  is  clear  that  the  connection  between  these  con- 
ditions is  not  merely  accidental.     On  the  contrary,  I 


DISEASES    OF    THE    CHOROID    COAT. 


345 


am  persuaded  that  a  definite  causative  relation  exists 
between  the  strain  of  accommodation,  the  miliary 
choroido-retinitis  to  which  it  gives  rise,  and  the  later 
occurrence  of  cataract  or  glaucoma,  as  the  case  may 
be.  Other  factors  doubtless  play  a  part,  especially 
with  reference  to  the  supervention  of  glaucoma,  but  the 
long-continued  accommodative  strain,  not  infrequently, 
is  the  dominant  one. 

How  many  of  these  serious  maladies  of  advanced  life 
might  be  prevented  by  the  early  recognition  and  careful 
correction  of  the  errors  of  refraction  with  which  they  are 
so  often  found  associated  it  is  difficult  to  say.  But  I  ven- 
ture to  predict  that  when  the  medical  profession  and  the 
laity  have  learned  how  important  a  role  these  errors 
play  in  the  causation  of  ocular  diseases,  and,  further- 
more, that  their  determination  and  correction,— so  far 
from  being  a  trivial  matter  to  be  left  to  the  tyro  who, 
calling  himself  an  "examining  optician,"  undertakes  to 
*' fit  glasses," — demand  the  best  efforts  of  the  physician 
trained  in  this  department  of  medicine,  there  will  be  a 
very  material  reduction  in  the  number  of  eyes  requiring 
operation  for  glaucoma  or  for  cataract,  and  probably, 
too,  of  eyes  in  which  sight  is  irretrievably  impaired 
through  pathological  changes  in  the  retina  or  its  blood- 
vessels. 

Treatment.- — In  choroiditis  of  syphilitic  origin  local 
remedies  are  of  but  little  value;  but  one  should  be  on 
the  lookout  constantly  for  the  supervention  of  iritis,  and 
immediately  upon  the  appearance  of  symptoms  indica- 
tive of  its  occurrence,  such  as  pericorneal  injection,  pain, 
photophobia,  and  lacrimation,  should  employ  atropin 
freely.  The  constitutional  remedies  chieHy  to  be  relied 
upon  are  mercury  and  potassium  iodid,  and  these  to  be 
effectual  must  be  given  persistently  and  in  liberal  doses. 


346  PREVALENT    DISEASES    OF    THE     EYE. 

The  biniodid  of  mercury  in  doses  of  a  sixteenth  of  a 
grain,  or  the  protoiodid  in  one-fourth  of  a  grain  doses, 
should  be  given  three  times  a  day,  and  with  either  of 
these  potassium  iodid  may  often  be  combined  advan- 
tageously. In  addition,  inunctions  of  mercurial  oint- 
ment should  be  employed  in  severe  or  intractable  cases. 
Heroic  doses  of  potassium  iodid  not  infrequently  prove 
valuable.  As  a  rule,  in  the  cases  due  to  inherited  lues 
less  energetic  treatment  is  demanded,  though  here,  too, 
it  must  be  persisted  in.  One  should  not  be  disap- 
pointed if  the  response  to  the  remedies  employed  is 
tardy,  for  this  is  what  must  be  expected. 

In  the  choroiditis  of  high  myopia  it  is  of  the  first  im- 
portance that  the  eyes  should  be  taxed  but  little  in  near 
vision,  and  that  carefully  adjusted  glasses  should  be 
prescribed — glasses  which,  as  a  rule,  leave  a  part  of  the 
myopia  uncorrected,  but  which  take  into  account  any 
astigmatism  or  muscular  fault  that  may  be  present. 
The  long-continued  use  of  the  lotion  of  opium  and  bor- 
acic  acid  is  also  of  undoubted  value.  It  should  be 
applied  at  bedtime  on  gauze  or  linen  pads,  and  the  pads, 
kept  in  place  by  a  light  bandage,  should  be  allowed  to 
remain  in  position  until  morning.  It  may  seem  that 
such  a  remedy,  applied  in  this  way,  could  hardly  be 
efficacious;  but  it  unquestionably  lessens  the  irritability 
of  the  eyes,  and  probably  reduces  the  hyperemia  of  the 
deeper  ocular  tunics.  We  know  that  belladonna  used 
in  a  similar  manner  finds  its  way  into  the  circulation  of 
the  eye,  and  produces  its  characteristic  effect,  and  there 
is  no  reason  why  opium  should  not  do  the  same. 

In  non-suppurative  traumatic  choroiditis  sodium 
salicylate,  in  generous  doses,  is  the  most  useful  rem- 
edy that  we  possess.  Mercury  also  is  at  times  service- 
able.    Atropin  and  the   lotion   of  opium   and   boracic 


DISEASES    OF    THE    CHOROID    COAT. 


347 


acid  are  indicated  when,    as    is    often    the    case,    pain 
and  photophobia  are  present. 


Fig.  133. — Sarcoma  of  the  choroid  with  complete  detachment  of  the  retina 
(Leber).  The  tumor,  G,  rises  from  the  choroid,  C,  which  ever\' where  lies 
in  contact  with  the  sclera.  The  retina,  N,  on  the  contrary,  is  detached 
entirely  from  its  bed  under  the  form  of  a  folded  funnel.  It  retains  its  con- 
nection only  with  the  papilla  behind,  and  with  the  choroid  along  the  ora 
serrata,  O,  in  front. 


Fig.    134. — Sarcoma   of   the   choroid,    advanced  stage   (Haab). 


As  might  be  supposed,  in  dealing  with  mihary  chor- 
oido-retinitis  the  most  important  indication  is  the  care- 
ful correction  of  the  refractive  error  or  muscular  fault 


34^  PREVALENT    DISEASES    OF    THE     EYE. 

which  has  brought  it  about.  Exceptionally,  prolonged 
rest  of  the  eyes  is  called  for;  but  usually  the  trouble 
itself  and  the  symptoms  which  characterize  it  disappear 
promptly  when  proper  glasses  are  prescribed.  The 
lotion  of  opium,  just  spoken  of,  is  very  useful  in  this 
condition  also,  and  the  patient's  general  condition, 
especially  the  digestive  apparatus  and  the  state  of  the 
bowels,  should  be  looked  after. 

Tumors  of  the  choroid  are  of  infrequent  occurrence, 
and  are  commonly  of  malignant  type,  sarcoma  of  the 
choroid  being  oftenest  encountered  (Figs.  133  and  134). 
As  soon  as  their  malignant  nature  is  recognized,  imme- 
diate enucleation  of  the  eye  is  demanded;  but  even  when 
this  measure  is  resorted  to  at  an  early  stage  of  their  de- 
velopment there  is  no  assurance  that  the  disease  will  not 
manifest  itself  elsewhere. 

Congenital  anomalies  of  the  choroid  are  compara- 
tively rare,  and  need  not  engage  our  attention. 

DISEASES  OF  THE  RETINA. 

RETINITIS. 

Retinitis,  or  inflammation  of  the  retina,  occurs  as  a 
primary  and  as  a  secondary  affection.  When  mild  in 
type,  and  attended  only  by  hyperemia  and  edema,  it  is 
known  as  serous  retinitis;  when  more  severe,  and  ac- 
companied by  hemorrhage  and  round-cell  infiltration, 
it  is  denominated  parenchymatous  retinitis.  Inflam- 
mation of  the  retina  is  not  attended,  as  might  be  sup- 
posed, by  photophobia,  nor  is  it  accompanied  by  pain. 
Impairment  of  vision  is  the  chief  subjective  symptom; 
enlargement  aad  sluggishness  of  the  pupil  are  almost 
the  only  objective  symptoms,  apart  from  the  evidence 
afforded  by  the  ophthalmoscope.  When  the  inflamma- 
tion involves  the  region  of  the  macula  the  disturbance 


DISEASES    OF    THE    RETINA. 


349 


of  sight  is  pronounced;  when  it  is  Hmited  to  the  outlying 
portions  of  the  retina  there  is  commonly  only  circum- 
scription of  the  visual  field,  which  may  cause  but  little 
annoyance.  Parenchymatous  retinitis  is  usually  bilat- 
eral, and  commonly  runs  a  tedious  course,  and,  if  un- 
checked, leads  to  atrophy  of  the  nervous  elements  of  the 
retina,  with  attendant  hypertrophy  of  the  supporting 
tissue,  and  obliteration  of  the  blood-vessels. 

The  usual  causes  of  primary  retinitis  are  syphilis, 
nephritis,  diabetes,  splenic  leucocythemia,  pernicious 
anemia,  gout,  and  angiosclerosis.  It  may  also  result 
from  embolism  or  thrombosis  of  the  central  artery  of  the 
retina,  or  one  of  its  chief  branches,  and  from  thrombosis 
of  the  central  vein,  while  exceptionally  it  is  produced 
by  some  direct  exciting  cause,  such  as  undue  exposure 
of  the  eye  to  the  direct  rays  of  the  sun  or  to  the  electric 
arc  light.  Prolonged  accommodative  strain  is  another 
cause,  though  this  commonly  gives  rise  to  a  choroido- 
retinitis,  of  which  we  have  already  spoken. 

Secondary  retinitis  is  usually  consequent  upon  inflam- 
mation of  the  uveal  coat  or  of  the  optic  nerve.  It  may 
occur  also  as  a  result  of  serious  injury  of  other  eye 
structures. 

Retinitis  Albuminurica  (Nephritic  Retinitis). — 
Retinitis  occurs  in  all  forms  of  kidney  disease  at- 
tended by  albuminuria,  but  especially  in  chronic  inter- 
stitial nephritis.  It  is  met  with  also  in  the  albumi- 
nuria of  pregnancy  and  in  that  of  scarlatina.  It  is  not 
infrequently  a  comparatively  early  symptom  of  nephri- 
tis, and  is  almost  always  bilateral.  It  is  said  that  a 
majority  of  the  patients  suffering  with  kidney  disease 
die  within  two  years  of  the  appearance  of  the  retinal 
lesion,  and  that  to  live  for  five  years  is  rare.  As  it 
commonly  involves  the  region  of  the  macula,  it  is  usually 


35°  PREVALENT    DISEASES    OF    THE     EYE. 

attended  by  marked  impairment  of  vision.  The  occur- 
rence of  a  hemorrhage  in  this  region  may  cause  a  sud- 
den and  pronounced  impairment  of  sight.  The  severity 
of  the  eye  lesion,  it  should  be  remarked,  does  not  bear  a 
constant  relation  to  the  severity  of  the  kidney  affection. 
The  retinal  changes  consist  of  degeneration  of  the 
walls  of  the  blood-vessels,  round-cell  infiltration,  numer- 
ous hemorrhages,  and  rapidly  occurring  fatty  degener- 


Fig.  135. — AlijU'iiinuriL  retinitis  (Haab). 

ation  of  the  infiltrate  and  of  the  retina  itself.  The 
ophthalmoscopic  picture  presented  by  these  changes 
is  very  characteristic  (Fig.  135),  and  for  this  reason 
it  often  happens  that  an  examination  of  the  eyes 
reveals  the  true  nature  of  the  patient's  malady  before 
other  suggestive  symptoms  have  manifested  themselves. 
The  discovery  of  retinitis  should  always  lead  to  a 
careful  analysis  of  the   urine. 


DISEASES    OF    THE    RETINA. 


35^ 


A  sudden  and  pronounced  impairment  of  vision,  due 
to  uremia,  may  occur  in  any  of  the  varieties  of  albumin- 
uria, but  especially  in  the  albuminuria  of  pregnancy  and 
in  that  due  to  the  eruptive  fevers  (uremic  amblyopia). 
With  improvement  in  the  patient's  general  condition 
vision  commonly  returns  to  its  former  standard. 

In  the  albuminuria  of  pregnancy  and  of  scarlatina 
the  prognosis  as  to  vision  is  favorable;  but,  as  might 
be  supposed,  the  outlook  is  grave  when  this  condition 
is  due  to  organic  disease  of  the  kidneys.  Even  under 
such  circumstances,  however,  I  have  occasionally  seen 
the  retinal  lesion  improve  decidedly,  and  seemingly  as 
a  result  of  the  treatment  instituted.  Fortunately,  sight 
is  seldom  completely  lost,  for  death  usually  occurs  be- 
fore this  happens. 

Treatment. — So  far  as  the  eyes  themselves  are  con- 
cerned the  treatment  consists  solely  in  care  in  their  use, — 
not  necessarily  absolute  avoidance  of  reading,  writing, 
etc.,  but  very  moderate  indulgence  in  such  occupa- 
tions— and  in  the  careful  adjustment  of  glasses  to 
correct  any  refractive  or  muscular  fault  that  may  be 
present.  This  latter  measure  is  of  much  importance, 
and,  by  relieving  the  eyes  of  all  strain,  may  do  more  than 
anything  else  to  preserve  the  sight.  Apart  from  these 
local  measures,  treatment  is  to  be  directed  to  the  neph- 
ritis and  to  the  patient's  general  condition.  Tincture  of 
iron,  in  liberal  doses,  is  at  times  distinctly  beneficial. 
Basham's  mixture  is  also  useful,  and  so,  in  some  in- 
stances, is  potassium  iodid,  administered  in  small  doses. 

Diabetic  Retinitis. — This  occurs  as  a  late  mani- 
festation of  the  disease,  and  is  always  bilateral.  It 
is  not  infrequently  complicated  by  cataract  and  oc- 
casionally by  plastic  iritis  or  glaucoma.  The  fundus 
changes  are  not  wholly  unlike  those  observed  in  neph- 


352  PREVALENT    DISEASES    OF    THE    EYE. 

ritic  retinitis,  but  are  less  sure  to  involve  the  region  of 
the  macula.  Hemorrhages  into  the  retina  are  common, 
and  extravasations  of  blood  into  the  vitreous  humor 
occur.  As  in  other  forms  of  retinitis,  the  extent  to 
w^hich  sight  is  impaired  depends  in  large  measure  upon 
the  involvement  or  non-involvement  of  the  macula  in  the 
inflammatory  process.  The  prognosis,  of  course,  is 
unfavorable,  and  depends  upon  whether  or  not  the 
patient's  general  condition  can  be  improved.  An  oph- 
thalmoscopic examination  is  demanded  w^henever  fail- 
ure of  sight  occurs  during  the  progress  of  a  case  of 
diabetes.  It  may  reveal  either  retinitis  or  incipient 
cataract. 

Treatmeiit. — Besides  moderation  in  the  use  of  the 
eyes  and  the  prescribing  of  suitable  glasses,  treatment 
consists  chiefly  in  regulating  the  diet  and  habits  of 
life  of  the  patient. 

Leucocythemic  Retinitis. — This  seldom  occurs 
except  in  the  splenic  variety  of  the  disease.  The  retinal 
changes  consist  of  emigration  of  leucocytes  and  numer- 
ous hemorrhages.  As  seen  with  the  ophthalmoscope, 
the  light  color  of  the  background  of  the  eye,  with  the 
distended  and  rose-red  veins,  the  contracted  and  orange- 
yellow  arteries,  and  the  pale  optic  disc  form  a  striking 
picture.  Both  eyes  are  in^  olved,  and  the  ocular  lesion 
commonly  increases  with  the  progress  of  the  general  dis- 
ease.    The  treatment  is  that  of  the  systemic  condition. 

Retinitis  of  Pernicious  Anemia. — This  affection 
closely  resembles  leucocythemic  retinitis,  and  the 
ophthalmoscopic  changes  are  of  much  the  same 
character.  One  or  both  eyes  may  be  involved,  and 
after  temporary  improvement  relapses  frequently  occur. 
The  prognosis   as  to  vision   is   distinctly  unfavorable. 

Treatment,  as  recommended  by  Osier,  consists  of  rest 


DISEASES  OF  THE  RETINA.  353 

in  bed,  with  a  light  nutritious  diet,  massage,  and  in- 
creasing doses  of  arsenic. 

Syphilitic  Retinitis. — SyphiHtic  inflammation  of 
the  retina,  without  accompanying  involvement  of  the 
choroid,  is  rare,  but  is  described  by  most  authors, 
and  is  said  to  occur  in  the  inherited  as  well  as  in  the 
acquired  form  of  the  disease.  Exudations,  especially 
along  the  retinal  vessels,  and  vitreous  opacities  make 
their  appearance,  while  hemorrhages  are  rare,  and  there 
is  an  absence  of  the  pigment  changes  seen  in  syphilitic 
choroido-retinitis.  One  or  both  eyes  may  be  involved, 
and  the  affection  may  develop  within  a  few  months 
of  the  initial  lesion  or  at  a  much  later  period.  The 
process  is  usually  a  chronic  one,  and  not  infrequently 
results  in  marked  impairment  of  sight.  If  treatment 
is  promptly  instituted,  however,  the  prognosis  is  not  un- 
favorable. 

Treatment. — Energetic  antisyphilitic  treatment  is 
indicated.  The  biniodid  of  mercury,  with  or  without 
potassium  iodid,  is  especially  useful,  and  in  individuals 
showing  an  insusceptibility  to  mercury,  its  administra- 
tion may  be  supplemented  by  inunctions  of  blue  oint- 
ment. 

Retinitis  from  Exposure  of  the  Eyes  to  In- 
tense Light. — Retinitis  resulting  from  undue  expo- 
sure of  the  eyes  to  the  direct  rays  of  the  sun — 
oftenest  brought  about  by  observing  an  eclipse  of  the 
sun  without  proper  protection  of  the  eyes — and  to  in- 
tense electric  light,  as  in  electric  welding,  usually  mani- 
fests itself  in  the  region  of  the  macula,  where  at  first 
edema,  and  later  miliary  pigment  changes,  are  observable 
with  the  ophthalmoscope.  The  visual  disturbance  is 
characterized  at  the  outset  by  a  persistent  after-image, 
and  this  is  followed  by  a  decided,  usually  small,  central 
23 


354  PREVALENT    DISEASES    OF    THE    EYE. 

scotoma,  which  may  be  attended  by  subjective  sensa- 
tions of  light.  From  the  action  of  the  electric  light, 
in  addition  to  the  retinitis,  considerable  ciliary  irritation 
and  conjunctivitis  sometimes  result,  an  effect,  it  would 
seem,  of  the  ultra-violet  rays,  comparable  to  that  which 
is  produced  by  the  too-prolonged  action  of  the  "X" 
rays  or  by  the  emanations  of  radium. 

The  symptoms  commonly  disappear  slowly,  and  the 
eyes  ultimately  resume  their  normal  state;  but  excep- 
tionally the  outcome  is  not  so  favorable,  and  a  more  or 
less  pronounced  impairment  of  central  vision  remains. 

Treatment  consists  in  complete  rest  of  the  eyes,  and 
in  their  protection  from  bright  light  by  smoke-tinted 
glasses.  The  lotion  of  opium  and  boracic  acid  is  indi- 
cated, and  the  occasional  administration  of  a  purgative 
may  do  good. 

Retinitis  Pigmentosa  (Pigmentary  Degenera- 
tion of  the  Retina). — This  singular  and  interest- 
ing affection,  which  invariably  involves  both  eyes, 
makes  its  appearance  in  childhood,  when  it  is  not 
congenital,  and  progresses  slowly  with  advancing 
age.  Little  is  known  as  to  its  etiology  except  that,  not 
infrequently,  inheritance  seems  to  be  an  important  fac- 
tor, and  that  it  is  met  with  sufficiently  often  in  the  off- 
spring of  consanguineous  marriages  to  make  the  fact 
noteworthy.  Probably  the  latter  circumstance  ex- 
plains its  frequent  association  with  congenital  anom- 
alies, such  as  harelip,  mental  deficiency,  deaf-mutism, 
etc.  From  five  to  ten  per  cent,  of  congenital  deaf- 
mutes,  it  is  said,  are  afflicted  with  this  disease.  In- 
stances in  which  cases  have  occurred  in  several  genera- 
tions of  the  same  family  are  not  uncommon.  For  some 
reason,  as  yet  not  understood,  females  are  less  suscep- 
tible to  the  disease  than  males. 


DISEASES  OF  THE  RETINA.  355 

Inherited  syphilis  is  usually  given  as  one  of  the 
causes  of  retinitis  pigmentosa.  My  own  experience  is 
not  in  accord  with  this  view,  and  I  am  disposed  to  be- 
lieve it  is  the  result  of  confounding  syphilitic  dissemi- 
nated choroido-retinitis  with  true  retinitis  pigmentosa, 
which  it  sometimes  closely  resembles. 

One  of  the  earliest  symptoms  of  the  disease,  and 
the  most  characteristic,  is  night-blindness;  progressive, 
concentric  contraction  of  the  visual  field  is  another 
prominent  symptom.  Ultimately  there  is  marked 
failure  of  central  vision,  though  complete  blindness  is 
rare,  or,  at  all  events,  does  not  come  on  until  quite  late 
in  life.  Nystagmus  is  not  infrequently  present,  espe- 
cially in  cases  of  congenital  origin. 

The  failure  of  vision  is  due  to  a  slowly  progressive 
atrophy  of  the  retina  and  optic  nerve,  attended  by 
marked  narrowing  of  the  retinal  vessels,  and  by  the 
peculiar  deposition  of  pigment  from  which  the 
disease  derives  its  name.  The  deposits  of  pigment, 
which  often  lie  along  the  course  of  the  vessels,  are 
stellate  in  form,  and  resemble  bone  corpuscles  as  seen 
with  a  microscope  of  low  power.  At  first  these  deposits 
are  confined  to  the  periphery  of  the  fundus,  and  are 
detected,  perhaps,  with  some  difficulty  with  the  ophthal- 
moscope; they  slowly  advance,  however,  toward  the 
optic  nerve  and  macula,  and  ultimately  are  scattered 
over  the  whole  background  of  the  eye.  The  ophthal- 
moscopic picture  presented  is  a  very  characteristic  one, 
and  should  not  be  mistaken  for  any   other   condition 

(Fig.   136). 

The  decline  of  vision,  as  has  been  said,  is  very  gradual, 
but  the  prognosis  as  to  the  final  outcome  is  most  un- 
favorable, for  treatment  is  of  little  or  no  avail.  In 
every  case  of  defective  night  vision,  especially  if  of  con- 


356  PREVALENT    DISEASES    OF    THE     EYE. 

siderable  duration  and  progressive  in  character,  the 
existence  of  retinitis  pigmentosa  should  be  suspected, 
and  a  careful  ophthalmoscopic  examination,  directed 
particularlv  to  the  periphen'  of  the  eve-grounds,  should 
be  made.  One  of  the  later  complications  of  the  disease, 
not  infrequentlv  observed,  is  the  development  of  pos- 
terior polar  cataract,  which,  of  course,  further  markedly 
impairs  vision. 


Fig.  136. — Advanced  stage  of  retinitis  pigmentosa.  Tlie  optic  nerve 
shows  pronounced  atrophy,  and  the  retinal  vessels  have  nearly  disappeared 
(Jaeger). 


Treatment. — As  pronounced  refractive  errors  are 
often  associated  with  retinitis  pigmentosa,  thev  should 
be  carefully  searched  for,  and  as  carefully  corrected 
h\  glasses  if  found  to  be  present.  Moderation  in  the 
use  of  the  e\'es  should  be  enjoined  and  the  a^■oidance 
of  occupations  which  involve  much  reading,  writing, 
sewing,  and  the  like.  Strvchnin  given  from  time  to 
time,  in  moderate  doses  and  for  considerable  periods, 


DISEASES    OF    THE    RETINA.  357 

seems  in  some  cases  to  be  of  benefit;  galvanism  also  is 
recommended,  and  potassium  iodid  may  be  tried  when 
other  measures  have  failed. 

Embolism  of  the  Central  Artery  of  the  Retina. 
— The  lodgment  of  an  embolus  in  the  central  artery  of 
the  retina,  which  is  usually  a  consequence  of  valvular 
disease  of  the  heart  or  of  aneurism,  causes  sudden  and 
complete  loss  of  sight  of  the  affected  eye.  In  rare 
instances  the  embolus  becomes  dislodged  or  breaks 
down,  and  vision  is  restored;  but  such  improvement 
in  sight  as  occurs  occasionally  from  the  establishment 
of  a  collateral  blood-supply  almost  always  proves 
to  be  but  temporary.  When  the  obstruction  takes 
place  in  a  branch  of  the  artery  central  vision  may  re- 
main unimpaired,  and  there  may  result  only  a  more  or 
less  marked  contraction  of  the  visual  field. 

Pronounced  edema  of  the  retina  develops  within  a 
few  hours  of  the  lodgment  of  the  embolus,  and  this  is 
accompanied  by  marked  diminution  in  the  size  of  the 
retinal  arteries.  Hemorrhages,  especially  in  the  macu- 
lar region,  may  occur.  Ultimately  atrophy  of  the 
retina  and  optic  nerve  ensues. 

The  picture  revealed  by  the  ophthalmoscope  is  very 
characteristic  and  striking  (Fig.  137).  The  edematous 
condition  of  the  retina  gives  to  the  general  eye-ground  a 
whitish  appearance;  but  as  the  edema  does  not  involve 
the  macula  the  red  color  of  the  choroid  shows  plainly  at 
this  point.  The  contrast  in  color  is  pronounced,  and 
the  condition  is  spoken  of  as  "the  cherry-red  spot  at  the 
macula." 

It  is  probable  that  a  not  inconsiderable  number  of 
the  cases  which  in  the  past  have  been  diagnosticated 
as  "embolism"  of  the  central  retinal  artery,  but  in 
which  none  of  the  cardiac  or  vascular  conditions  apt 


358  PREVALENT    DISEASES    OF    THE     EYE. 

to  give  rise  to  the  formation  of  an  embolus  was  present, 
were  really  cases  of  rapidly  forming  thrombotic  obstruc- 
tion of  the  artery. 

Treatment. — This  has  for  its  object  the  possible  dis- 
lodgment  of  the  embolus,  so  that  it  may  find  its  way  into 
one  of  the  subdivisions  of  the  artery,  where  the  ill  con- 


Fig.   137. — Embolism — or  thrombosis — of  the  central  artery  of  the  retina 

(Haab). 


sequences  of  its  presence  will  be  of  less  moment.  With 
this  end  in  view  the  eye  should  be  rather  energetically 
massaged,  and  nitrite  of  amyl  should  be  administered 
by  inhalation  for  the  purpose  of  causing  transient  dila- 
tation of  the  artery.  These  measures  have  in  some 
instances  proved  effectual. 


DISEASES  OF  THE  RETINA.  359 

Thrombosis  of  the  central  artery  of  the  retina 

commonly  results  from  degenerative  changes  in  the 
arterial  coats  or  from  alterations  in  the  compo- 
sition of  the  blood.  The  symptoms  which  attend  it 
are  similar  to  those  observed  in  embolism,  except  that 
the  final  loss  of  sight  is  often  preceded  by  transient 
obscurations  of  vision  and  by  attacks  of  giddiness, 
faintness,  and  headache.  The  ophthalmoscopic  pic- 
ture is  essentially  the  same.    (See  Fig.  137.) 

It  seems  probable  that  the  cases  of  sudden  loss  of 
sight  following  severe  hemorrhage,  especially  hem- 
orrhage from  the  stomach,  are  due  in  most  instances 
to  thrombotic  obstruction  of  the  retinal  artery,  excep- 
tionally, perhaps,  to  similar  obstruction  of  the  retinal 
vein.* 

The  treatment  is  the  same  as  that  employed  in  em- 
bolism. 

Thrombosis  of  the  central  retinal  vein  occurs 
usually  in  elderly  persons  who  are  afflicted  with  or- 
ganic disease  of  the  heart  or  angiosclerosis;  it  may 
result  also  from  alterations  in  the  state  of  the  blood, 
such  as  occur  from  excessive  hemorrhage,  or  in  conse- 
quence of  orbital  disease  or  disease  of  the  cavernous 
sinus.  Facial  erysipelas,  through  extension  to  the  orbit, 
may  give  rise  to  it.     One  or  both  eyes  may  be  involved. 

Loss  of  sight  is  not  so  sudden  as  in  embolism  of  the 
artery,  and  the  prognosis  is  somewhat  less  hopeless, 
though  blindness  from  atrophy  of  the  retina  and  optic 
nerve  is  the  usual  outcome.     In  some  instances  a  glau- 

*  In  the  report  of  "A  case  of  atrophy  of  the  optic  nerve  following 
hemorrhage  from  the  stomach,  with  a  consideration  of  the  causes  of 
post-hemorrhagic  blindness,"  published  in  the  "Am.  Journal  of  Oph- 
thalmology" for  May,  1899,  and  in  the  "Johns  Hopkins  Hospital  Bul- 
letin" of  the  same  date,  this  view  was  advocated  by  the  author,  and 
evidence  set  forth  in  support  of  it. 


360  PREVALENT    DISEASES    OF    THE    EYE. 

comatous  condition  supervenes,  and  gives  rise  to  much 
suffering. 

The  ophthalmoscope  shows  edema  of  the  retina  with, 
perhaps,  more  definite  areas  of  exudation,  enormous 
distention  and  great  tortuosity  of  the  retinal  veins,  and 
numerous  flame-shaped  hemorrhages  scattered  over 
the  entire  fundus  (Fig.  138).     "Hemorrhagic  retinitis" 


Fig.  138. — Thrombosis  of  the  central  retinal  vein  (Haab). 

w^as  the  name  formerly  given  to  this  condition,  before 
its  essential  nature  was  understood. 

Treattnent  is  of  but  little  avail.  An  energetic  cathar- 
tic,  followed  by  potassium  iodid,  may  possibly  accom- 
plish some  good. 

Detachment  of  the  Retina. — In  view  of  the  fact 
that  the  retina  is  attached  only  about  the  optic  nerve 
margin  and  at  the  ora  serrata,  and  that  elsewhere  it  is 
kept  in  apposition  with  the  choroid  simply  through  the 


DISEASES    OF    THE    RETINA.  361 

support  afforded  by  the  vitreous  humor,  it  is  httle  matter 
for  surprise  that  it  should  at  times  become  "detached," 
or  separated  from  the  other  coats  of  the  eye.  Indeed, 
the  wonder  is  that  this  misadventure  does  not  happen 
more  frequently  than  it  does;  and  I  can  not  but  feel 
that  some  of  the  elaborate  and  far-fetched  theories 
which  have  been  advanced  to  explain  its  occurrence  are 
as  uncalled  for  as  they  are  unsatisfying.  For  example, 
one  of  these  theories,  which  has  been  accepted  by 
many,  holds  that  bands  which  have  formed  in  the  vitre- 
ous humor,  by  contraction,  drag  upon  the  retina  with 
such  force  as  finally  to  tear  a  rent  in  it,  and  that  through 
this  rent  fluid  from  the  vitreous  chamber  passes,  and 
causes  the  detachment.  Why  the  retina  does  not  yield 
directly  to  the  traction,  and  what  causes  it,  since  it  is 
not  adherent  to  the  choroid,  to  resist  the  drag  upon  it 
to  the  point  of  being  torn,  the  proposers  of  the  theory  do 
not  explain;  nor  do  they  tell  us  why  the  subretinal  fluid 
might  not  be  supplied  by  the  vascular  uveal  coat  quite 
as  well  as  by  the  non-vascular  vitreous  body. 

As  a  matter  of  fact,  detachment  of  the  retina,  when 
it  is  not  due  to  a  serious  traumatism,  usually  occurs  in 
eyes  which  have  been  the  seat  of  long-standing  disease, 
especially  disease  of  the  uveal  coat,  myopia  of  high  grade 
being  the  condition  in  which  it  oftenest  takes  place. 
It  is  also  a  common  result  of  the  development  of  intra- 
ocular tumors.  That  in  these  several  conditions  a  pre- 
disposition exists  to  the  occurrence  of  hemorrhagic  or 
serous  effusion  from  the  very  vascular  choroid  coat 
goes  without  saying,  and  it  is  doubtless  in  this  way  that 
detachment  of  the  retina  usually  is  brought  about,  the 
immediate  cause  of  such  an  effusion  being,  very  often, 
a  violent  spell  of  coughing  or  vomiting,  a  fall,  a  blow 
upon  the  head,  or  an  unusual  strain,  as  in  lifting  a  heavy 


362  PREVALENT    DISEASES    OF    THE     EYE. 

weight.  In  intraocular  growths  there  is  also,  not  infre- 
quently, a  mechanical  elevation  of  the  retina  by  the 
growth  itself,  and  in  high  myopia  the  staphylomatous 
yielding  of  the  sclera  at  the  posterior  pole  of  the  eye  is 
an  additional  factor  tending  to  promote  separation  of 
the  retina  from  the  outer  tunics. 

The  detachment  may  begin  at  any  point,  and  may 
be  partial  or  complete.  When  it  commences  in  the 
upper  part  of  the  retina  it  usually  extends  downward, 
owing  to  the  gravity  of  the  subretinal  fluid,  and  as  this 
takes  place  the  upper  and  first  detached  portion  may 
resume  its  normal  position  with  reference  to  the  choroid, 
a  striking  illustration,  it  would  seem,  of  the  important 
role  which  the  eff^usion  plays  in  the  process.  Strictly 
speaking,  the  retina  never  becomes  completely  detached; 
for,  though  everywhere  else  separated,  it  always  re- 
mains attached  at  the  optic  nerve  entrance  and  at  the 
ora  serrata,  presenting  under  these  circumstances  an 
appearance  suggestive  of  a  nearly  closed  umbrella  (see 

Fig-  133)- 

Besides  causing  marked  impairment  of  vision,  the 
degree  of  impairment  depending  largely  upon  its  loca- 
tion and  extent,  detachment  of  the  retina  is  usually 
attended  by  subjective  light  sensations  and  by  a  "flick- 
ering" and  confusion  of  sight  that  make  an  eye  in  which 
this  condition  is  present  a  source  of  much  greater  annoy- 
ance to  its  unfortunate  possessor  than  if  it  were  quite 
blind.  There  are  two  ways  in  which  detachment  of  the 
retina  may  impair  vision.  In  the  first  place,  the  sepa- 
rated portion  of  the  retina  is  itself  incapable  of  useful 
vision;  in  the  next  place,  it  may  hang  or  float  in  front 
of  a  part  of  the  retina  which  is,  perhaps,  in  a  nearly  or 
quite  normal  condition,  the  macular  region,  for  example, 
and  cut  off^  the  light  from  it.     If  the  macular  region  is 


DISEASES    OF    THE    RETINA.  363 

involved  in  the  detachment  or  is  covered  by  it  in  the 
manner  just  described,  the  sight  of  the  eye  will  be  of 
but  little  value.  On  the  other  hand,  if  the  detachment 
is  confined  to  the  periphery  of  the  retina,  good  central 
vision  may  be  present,  and  there  may  be  only  a  limita- 
tion of  the  visual  field.  A  late  complication,  more  apt 
to  occur  in  myopic  eyes,  is  the  development  of  cataract. 

When  the  symptoms  described  make  their  appear- 
ance, as  they  usually  do,  suddenly,  and  especially  in  an 
eye  known  to  be  decidedly  myopic,  retinal  detachment 
should  be  suspected,  and  an  ophthalmoscopic  examina- 
tion should  be  made.  This  view  would  be  strengthened 
if  the  tension  of  the  eye  was  found  to  be  below  normal; 
iforthis  is  usually  the  case  in  uncomplicated  detachment 
of  the  retina.  On  the  other  hand,  if  increased  tension 
of  the  globe  is  found  in  association  with  retinal  detach- 
ment the  presence  of  an  intraocular  growth  is  to  be 
feared. 

The  prognosis  in  detachment  of  the  retina  is  most 
unpromising.  In  rare  instances  a  spontaneous  re- 
covery takes  place,  and,  almost  as  rarely,  a  recovery  oc- 
curs seemingly  as  a  result  of  treatment.  Usually  the 
detachment  increases,  and  vision  goes  from  bad  to 
worse.  Unless  some  inflammatory  complication  en- 
sues pain  is  not  experienced.  The  affection  is  com- 
moner in  males  than  in  females,  probably  because  they 
are  more  liable  to  such  accidents  as  may  bring  it  about, 
and  occurs  much  oftener  in  advanced  lite  than  in  youth. 

Treatment. — This  consists,  at  the  outset,  in  rigid  con- 
finement to  bed  and  in  the  administration  of  increasing 
doses  of  pilocarpin,  so  that  marked  salivation  and  sweat- 
ing may  be  induced.  Later  potassium  iodid  may  be 
substituted  for  the  pilocarpin.  Avoidance  of  consti- 
pation   is    indicated.       Subconjunctival   injections    of 


364  PREVALENT    DISEASES    OF    THE    EYE. 

Sterile  salt  solution  are  worthy  of  trial,  though  the  results 
obtained,  as  in  all  other  methods  of  treatment,  are  usu- 
ally disappointing.  The  injections  should  be  repeated 
once  in  two  or  three  days,  the  strength  of  the  solution 
being  increased  gradually  from  two  per  cent,  to  five  per 
cent,  and  the  quantity  injected  from  15  to  25  minims. 
If  improvement  is  manifested,  the  treatment  should  be 
persisted  in  for  several  weeks. 

Numerous  operative  procedures  have  been  suggested 
for  the  cure  of  this  condition,  when  less  radical  measures 
have  proved  unavailing.  The  most  rational  of  these, 
and  the  one  as  apt  to  prove  efficacious  as  any,  consists 
in  the  drawing  off  of  the  subretinal  fluid  by  means  of  an 
incision,  made  subconjunctivally,  through  the  sclera 
at  a  point  corresponding  with  the  detachment.  With 
careful  antiseptic  precautions  this  procedure  is  attended 
with  little  risk.  Rest  in  a  recumbent  posture  for  some 
days  after  the  operation  should  be  enjoined.  It  is 
claimed,  by  Stillson,  that  more  permanent  results  are 
obtained  from  perforating  the  sclera  at  one  or  two 
points  beneath  the  detachment  by  means  of  the  galvano- 
cautery.  I  have  had  no  experience  with  this  method, 
but  it  impresses  me  as  being  a  rather  severe  procedure. 

Glioma  of  the  Retina. — Although  this  very  ma- 
lignant intraocular  tumor  is  certainly,  and  it  mav  be 
added  fortunately,  not  one  of  the  commoner  diseases 
of  the  eye,  it  has  seemed  to  me  best  to  treat  of  it,  for  the 
reason  that  the  early  recognition  of  its  existence  is  of  the 
first  importance,  and  before  such  cases  are  brought 
to  the  attention  of  the  specialist  thev  are  very  apt  to  fall 
under  the  observation  of  the  general  practitioner.  It  is 
true  that,  in  its  early  stages,  a  positive  diagnosis  can  not 
be  made  without  the  aid  of  the  ophthalmoscope;  never- 
theless   a  very  shrew^d   guess  as  to  what  the  trouble  is 


DISEASES    OF    THE    RETINA.  365 

may  be  hazarded  as  a  result  simply  of  a  careful  daylight 
inspection  of  the  eye,  aided  by  the  employment  of  a 
mydriatic. 

Glioma  of  the  retina  is  essentially  a  disease  of  child- 
hood, and  generally  makes  its  appearance  during  the 
first  three  years  of  life;  indeed,  it  is  not  infrequently 
of  congenital  origin.  In  about  one  case  in  four  both 
eyes  are  involved,  and  it  occurs  with  equal  frequency 
in  males  and  in  females.  It  has  its  starting-point  com- 
monly in  the  inner  granular  layer  of  the  retina,  and  is 
of  rapid  growth.  It  shows  a  strong  disposition  to  in- 
vade the  optic  nerve,  and  in  time  causes  a  rupture  of 


Fig.  139. — Glioma  of  the  retina,  early  stage  (Haab). 

the  eyeball,  usually  either  in  the  neighborhood  of  the 
optic  nerve  or  through  the  cornea. 

In  its  early  stages  it  is  attended  neither  by  pain  nor 
by  external  signs  of  inflammation.  The  first  evidences 
of  its  existence  are  a-  somewhat  enlarged  and  sluggish 
pupil  and  a  peculiar  yellowish  or  grayish  reflex  from 
the  pupil,  with  decided  impairment  of  the  sight  of  the  af- 
fected eye,  though  the  determination  of  this  point  is 
often  difficult,  because  of  the  early  age  at  which  it  com- 
monly develops.  This  striking  appearance  of  the  pupil 
led  the  earlier  authors  to  designate  the  condition  "am- 
aurotic cat's  eye"  (Fig.  139). 

As  the  tumor  increases  in  size  there  is  usually  an 
elevation  of  the  intraocular  tension,  and  when  this  is  at 


366 


PREVALENT    DISEASES    OF    THE     EYE. 


all  pronounced  pain  manifests  itself.  At  this  period 
several  enlarged  and  tortuous  subconjunctival  vessels 
often  make  their  appearance.  Before  long  the  shape 
of  the  eye  undergoes  alteration,  the  iris  becomes  muddy, 
the  cornea  cloudy,  and  there  is  great  intensification  of 
the  pain;  and  presently  rupture  of  the  eyeball  occurs. 
If  this  takes  place  posteriorly  pronounced  proptosis 
quickly  develops ;  if  anteriorly ,  a  fungoid  mass  sprouts  out 
rapidly  from  the  place  of  rupture  (Fig.  140),  and  increases 
in  size  so  fast  that  in  a  comparatively  short  time  it  may 
be  as  large,  or  nearly  as  large,  as  the  child's  head,  and  we 


'^h^'i.^ 


Fig.   140. — Glioma  of  the  retina,  more  advanced  stage  (Haab). 


have  the  condition  which  formerly  was  known  as"/""" 
gus  hematodes  oculi."  In  the  meantime,  by  extension 
along  the  optic  nerve,  the  disease,  perhaps,  has  reached 
the  brain;  or,  less  frequently,  by  metastasis,  has  invaded 
the  liver  or  other  distant  organs,  and  death,  not  any  too 
soon,  comes  to  put  an  end  to  the  sufferings  of  the 
wretched  little  patient.  There  are  few  tumors  which 
are  as  malignant  as  glioma  of  the  retina,  and  there  are 
not  many  diseases  in  which  the  prognosis  is  so  wholly 
unpromising. 

Treatment  consists  in  enucleation  ot  the  eye  at  the 
earliest  moment  possible  after  the  establishment  of  the 


DISEASES    OF    THE    OPTIC    NERVE.  367 

diagnosis,  care  being  taken  to  divide  the  optic  nerve  as 
far  behind  the  eyeball  as  practicable.  If  this  is  done 
before  the  growth  has  invaded  the  orbit  or  has  extended 
to  the  optic  nerve,  there  will,  in  all  probability,  be  no 
local  return  of  the  disease,  and,  in  very  exceptional  in- 
stances, no  development  of  it  elsewhere.  Usually,  how- 
ever, the  child  dies  within  two  or  three  years,  with  symp- 
toms which  indicate  that  the  growth  has  recurred  in  the 
brain. 

If  the  tumor  has  invaded  the  orbit  not  only  the  eye, 
but  the  whole  contents  of  the  orbit  should  be  removed, 
although  even  when  this  is  done  in  the  most  radical 
manner  a  local  recurrence  of  the  growth  is  extremely 
probable. 

DISEASES  OF  THE  OPTIC  NERVE. 

OPTIC  NEURITIS. 

Two  principal  varieties  of  inflammation  of  the  optic 
nerve  are  recognized — a  usually  more  intense  form, 
which  tends  to  involve  the  nerve  throughout  its  whole 
course,  is  commonly  consequent  upon  intracranial  dis- 
ease, is  nearly  always  bilateral,  and  is  attended  by 
marked  inflammatory  changes  in  the  papilla;  and  a  less 
intense  form,  which  is  limited  to  the  orbital  portion 
of  the  nerve,  has  no  relation  to  intracranial  disease, 
is  usually  monolateral,  and  is  accompanied  by  relatively 
slight  intraocular  changes.  The  last-named  variety, 
known  as  retrobulbar,  or  orbital,  neuritis,  is  a  type  of 
peripheral  neuritis,  and  occurs  as  an  acute  and  as  a 
chronic  affection.  The  first-mentioned  variety,  now 
commonly  known  as  intraocular  neuritis,  papillitis,  or 
choked  disc,  was  formerly  subdivided  into  descenduig 
neuritis  and  intraocular  neuritis  or  choked  disc,  and, 
though    definite    pathologico-anatomical    evidence  to 


368 


PREVALENT    DISEASES    OF    THE    EYE. 


support  this  classification  is  lacking,  from  a  clinical 
standpoint  there  seem  to  be  good  reasons  for  adhering 
to  it. 

According  to  this  view,  a  ''descending"  optic  neuritis 
is  an  inflammation  of  the  optic  nerve  in  which  the  in- 
flammatory process,  as  the  name  indicates,  progresses 
along  the  optic  nerve  from  the  brain  to  the  eye;  while 
a  "choked  disc,"  or  "intraocular  neuritis,"    is  one  in 


Fig.  141. — Longitudinal  section  of  the  optic  nerve-head  (Piersol):  a,  a, 
bundles  of  optic  nerve  fibers,  which  spread  out  over  retina  at  a',  a';  b,  layers 
of  retina;  c,  choroid;  d,  sclera,  continued  across  optic  nerve  as  the  lamina 
cribrosa;  e,  g,  i,  respectively  the  pial,  arachnoid,  and  dural  sheaths  of  optic 
nerve,  enclosing  subdural  and  subarachnoidal  lymph-spaces;  /,  /',  retinal 
blood-vessels  cut  loncritudinallv. 


which  the  inflammation,  believed  to  be  caused  by  ob- 
struction of  the  blood-  or  lymph-currents  of  the  optic 
nerve,  or  by  the  presence  of  toxins  or  other  pathological 
products  in  the  lymph-channels  of  the  nerve  (Fig.  141), 
begins  at  or  in  the  neighborhood  of  the  papilla,  and  tends 
to  extend  thence  toward  the  brain.  Both  of  these  types 
of  optic  neuritis  are  characterized  by  vascular  congestion 
and  swelling  of  the  papilla  and  by  engorgement  and 


DISEASES    OF    THE    OPTIC    NERVE. 


369 


tortuosity  of  the  central  retinal  veins;  but  this  swelling 
and  the  engorgement  of  the  retinal  veins  are  much  more 
marked  in  choked  disc  than  in  descending  neuritis,  and 
for  this  reason  it  is  usually  possible,  with  the  ophthalmo- 
scope, to  differentiate  the  two  forms  (Fig.  142).  In  addi- 
tion to  the  engorgement  of  the  veins  and  the  swelling  of 


Fig.    142. — Chukcd  disc,  or  papillitis  (Haab). 


the  papilla,  which  latter  is  due  to  edema  and  inflamma- 
tory exudation  as  well  as  to  hyperemia,  and  which,  ex- 
tending somewhat  into  the  retina,  obliterates  the  usually 
well-defined  margin  of  the  disc,  both  types  are  com- 
monly attended  by  hemorrhages  upon  and  around  the 
papilla,  and  not  infrequently  by  inflammatory  changes 
in  the  neighboring  portions  of  the  retina.  When  these 
24 


37° 


PREVALENT    DISEASES    OF    THE     EYE. 


changes  in  the  retina  are  pronounced  the  condition  is 
called  neuro-retinitis. 
Choked  Disc  (Papillitis).  —  In  this  type  of  intraocu- 


Eig.  143. — From  a  photo-micrograph  b}  Dr.  James  Wallace  of  a  section  of  a 
choked  disc  prepared  by  Dr.  William  Thomson. 


lar  neuritis,  the  supposed  etiology  of  which  has  been 
referred  to,  and  which,  as  has  been  said,  is  characterized 
by  great  swelling  of  the  papilla  and  great  engorgement 
of  the  retinal  veins  (Fig.  143),  sight  is  often,  and  it  may 


DISEASES    OF    THE    OPTIC    NERVE.  371 

be  for  a  long  time,  insignificantly  impaired,  the  impair- 
ment being  very  much  less  than  the  pronounced  fundus 
changes  would  lead  one  to  expect.  Not  infrequently 
an  enlargement  of  the  normal  "blind  spot"  is  the  only 
visual  disturbance  observed,  until  finally  atrophy  of  the 
nerve-fibers  ensues,  when,  if  this  is  complete,  sight  is 
entirely  lost.  Owing  to  this  circumstance  and  the  fur- 
ther fact  that,  except  perhaps  for  a  slight  dilatation 
and  sluggishness  of  the  pupil,  the  eye  exhibits  no  ex- 
ternal evidences  of  the  serious  malady  with  which  it  is 
afflicted,  it  often  happens  that  the  true  condition  is  first 
discovered  not  by  the  oculist  but  by  the  physician  con- 
cerned with  affections  of  the  brain  and  nervous  system, 
whose  advice  is  sought  for  the  relief  of  headache  or 
other  symptoms  pointing  to  intracranial  disease.  The 
process  is  a  chronic  one,  often  lasting  for  months,  and, 
as  has  been  intimated,  it  usually  ends  in  atrophy  of  the 
nerve  and  loss  of  sight. 

The  commonest  cause  of  choked  disc  is  intracranial 
tumor,  though  almost  any  coarse  disease  of  the  brain 
may  give  rise  to  it.  The  character  of  the  tumor, 
whether  malignant  or  benign  or  of  syphilitic  origin, 
and  its  size  and  location  seem  to  have  but  little  influence 
in  determining  the  result,  so  far  as  the  involvement  of  the 
optic  nerve  is  concerned.  Optic  neuritis,  and  usually [ 
of  the  choked  disc  type,  is  present  in  from  eighty  to 
ninety  per  cent,  of  intracranial  new-growths.  It  is\ 
obvious,  therefore,  that  its  existence,  while  it  throws  no 
light  upon  the  location  of  the  growth,  is  of  great  diag- 
nostic value  in  this  class  of  cases,  and  that  it  should  be 
sought  for  ophthalmoscopically  whenever  there  is  reason 
to  suspect  the  presence  of  a  brain  tumor. 

Other  conditions  which  may  give  rise  to  choked  disc 
are  meningitis,  acute  and  chronic, — in  children  tuber- 


372  PREVALENT    DISEASES    OF    THE     EYE. 

culous  meningitis  especially, — abscess  and  softening  of 
the  brain,  thrombosis  of  the  sinuses,  hydrocephalus, 
traumatic  lesions  of  the  head,  the  acute  infectious 
diseases,  such  as  scarlet  fever,  smallpox,  measles, 
diphtheria,  influenza,  pneumonia,  and  typhoid  fever; 
disturbances  of  nutrition,  such  as  occur  in  nephritis, 
diabetes,  disorders  of  menstruation,  pregnancy,  and  the 
puerperal  state;  syphilis,  either  directly  or  through  the 
development  of  gummata,  meningitis  or  periostitis;  and, 
finally,  aflPections  of  the  orbit — new-grov^^ths,  periostitis, 
etc.  When  arising  from  pathological  changes  in  the 
orbit  choked  disc  is  usually  monolateral,  but  under 
other  circumstances  it  is  almost  always  bilateral. 

Descending  optic  neuritis,  characterized,  as  has 
been  said,  by  less  marked  swelling  of  the  papilla, 
by  decidedly  less  engorgement  and  tortuosity  of  the 
retinal  veins,  and,  perhaps,  by  greater  disposition  to 
involvement  of  the  retina,  is  distinctly  a  disease  of  in- 
tracranial origin.  Its  most  common  cause,  probably,  is 
basilar  meningitis,  especially  that  of  tuberculous  origin, 
which  is  usually  accompanied  by  inflammation  of  the 
contiguous  brain  substance,  though  it  may  be  produced 
by  a  tumor  situated  at  the  base  of  the  brain,  and  which 
has  given  rise  to  a  localized  cerebritis.  It  commonly 
runs  a  less  protracted  course  than  the  choked  disc  type 
of  optic  neuritis,  and  vision  is  sooner  impaired. 

As  to  the  ultimate  outcome  of  the  two  conditions 
— choked  disc  and  descending  optic  neuritis — the 
prognosis  is  much  the  same.  When  either,  as  is  so 
often  the  case,  is  dependent  upon  incurable  intracranial 
disease,  or  upon  such  irremediable  afi^ections  as  chronic 
nephritis,  diabetes,  and  the  like,  it  is  thoroughly  bad; 
but,  on  the  other  hand,  when  due  to  affections  that  are 
themselves   amenable  to  treatment,   such   as   syphilis, 


DISEASES    OF    THE    OPTIC    NERVE.  373 

the  acute  infectious  diseases,  rheumatism,  etc.,  it  is 
more  hopeful,  and  under  such  circumstances  much  may 
be  accomphshed  by  energetic  and  promptly  employed 
remedial  measures. 

Treatment. — This,  of  course,  depends  in  large  meas- 
ure upon  the  condition  that  has  given  rise  to  the  neuritis. 
If  it  be  consequent  upon  intracranial  disease  every  effort 
should  be  made  to  combat  this,  and  in  exceptional  in- 
stances radical  operative  procedures — the  removal  ot 
a  cerebral  tumor,  for  example — may  be  demanded. 
Mercury,  in  liberal  doses,  and  potassium  iodid,  heroically 
administered,  are  the  constitutional  remedies  chiefly  to 
be  relied  upon,  not  only  because  they  may  possibly 
exert  a  favorable  influence  upon  the  intracranial  affec- 
tion, but  because  of  their  direct  effect  upon  the  neuritis. 
They  should  be  employed  the  more  persistently  when- 
ever there  is  reason  to  believe  that  syphilis  may  be  a 
factor,  direct  or  indirect,  in  the  causation  of  the  neuritis; 
for  under  such  circumstances  much  may  be  hoped  for 
from  their  influence.  Pilocarpin,  so  administered  as  to 
produce  marked  salivation  and  sweating,  is  another 
remedy  which  at  times  proves  useful,  while  sodium 
salicylate  m  large  doses  may  be  beneficial,  especially, 
but  not  solely,  in  cases  of  rheumatic  origin. 

The  urine  should  be  examined  in  every  case  of 
optic  neuritis,  as  this  may  afford  important  infor- 
mation as  to  its  etiology  and  as  to  the  line  of 
treatment  to  be  employed.  The  bowels  should  be 
regulated,  any  tendency  to  constipation  being  care- 
fully controlled,  and  from  time  to  time  an  ener- 
getic purgative  may  be  given  with  good  effect.  If 
the  neuritis  be  dependent  upon  orbital  disease  this 
should  receive  appropriate  treatment,  operative  or 
otherwise.     From  the  application  of  remedies  to  the 


374  PREVALENT    DISEASES    OF    THE     EYE. 

eye  itself  little  benefit  is  likely  to  result;  it  should,  how- 
ever, be  protected  from  undue  exposure  to  bright  light, 
and  should  be  given  as  complete  rest  as  possible. 
Prompt  response  to  treatment  is  hardly  to  be  expected, 
even  in  the  more  favorable  cases. 

Retrobulbar  Neuritis  (Orbital  Neuritis). — Two 
types  of  retrobulbar  neuritis  are  recognized,  an  acute 
and  a  chronic  form.  They  resemble  each  other  chiefly 
in  that  in  each  the  inflammation  aff"ects  the  orbital 
portion  of  the  nerve,  and  that  in  each  the  papillo- 
macular  fibers — those  fibers  which  supply  the  macular 
region — are  the  ones  first  attacked.  In  each,  too,  if 
the  process  is  not  arrested,  all  of  the  nerve-bundles  in 
time  are  involved,  and  ultimately  undergo  atrophy. 

Acute  Retrobulbar  Neuritis. — There  are  a  va- 
riety of  causes  which  seem  to  be  capable  of  giving 
rise  to  this  aflPection  The  most  common  are  syphilis, 
rheumatism,  gout,  the  exanthemata,  influenza,  sudden 
suppression  of  the  menstrual  flow,  chilling  of  the  surface 
of  the  body  from  exposure  to  wet  and  cold,  and  the 
ingestion  of  considerable  quantities  of  methvlic  or  wood 
alcohol.  It  may  also  be  secondary  to  other  orbital  dis- 
ease or  to  disease  of  the  sphenoid  sinus.  It  is  usually 
unilateral,  and  the  symptoms  which  indicate  its  exis- 
tence are  rapid  decline  of  central  vision,  moderate 
dilatation  and  sluggishness  of  the  pupil  in  response  to 
light,  and  not  infrequently  retrobulbar  pain  when  the 
eye  is  turned  in  different  directions  or  is  pressed  toward 
the  apex  of  the  orbit. 

As  the  nerve  fibers  which  supplv  that  portion  of  the 
retina  lying  between  the  optic  disc  and  the  macula  are 
those  primarily  affected,  the  visual  disturbance  mani- 
,  fests  itself  at  first  in  the  form  of  a  paracentral  scotoma — 
a  circumscribed  area  of  impaired  vision  near  to,  and  per- 
haps involving,  the  center  of  the  visual  field.     At  the 


DISEASES    OF    THE    OPTIC    NERVE. 


375 


outset  this  impairment  of  vision  may  be  slight,  amount- 
ing only  to  inability  to  distinguish  colors,  but  it  may 
increase  rapidly,  so  that  within  this  area  objects  can  no 
longer  be  distinguished;  and,  if  the  inflammation  extends 
from  the  papillo-macular  fibers  to  the  rest  of  the  nerve, 
a  general  disturbance  of  vision  will  ensue,  which  may 
eventuate  in  total  loss  of  sight. 

The  disease  runs  a  much  less  protracted  course  than 
do  the  intraocular  forms  of  neuritis,  and  the  prognosis, 
as  a  rule,  is  less  grave;  still,  the  outcome  is  always  uncer- 
tain, and  permanent  impairment  of  vision,  especially 
a  persistent  central  scotoma,  may  result. 

Treatment. — Potassium  iodid,  alone  or  in  combination 
with  biniodid  of  mercury,  sodium  salicylate,  especially 
when  the  aff^ection  is  of  rheumatic  origin,  and,  at  a 
later  stage,  strychnin,  are  the  remedies  of  greatest  value. 
Local  treatment,  except  perhaps  the  abstraction  of  blood 
by  leeches,  or  the  application  of  a  blister  to  the  forehead 
or  temple,  is  of  little  efficacy.  Complete  rest  of  the 
eyes  and  their  protection  from  bright  light  should,  of 
course,  be  enjoined. 

Chronic  Retrobulbar  Neuritis  (Toxic  Ambly- 
opia).— This  disease,  as  the  subtitle  indicates,  is 
caused  by  certain  toxic  agents,  which,  acting  usually 
for  a  considerable  time  upon  the  system,  eventually 
induce  a  chronic,  peripheral,  interstitial  inflammation 
of  the  optic  nerve.  As  in  the  acute  form  of  the  disease, 
the  papillo-macular  fibers  are  the  first  to  suffer.  (See 
Plate  IX.)  The  afl^ection  is  commonly  bilateral,  and 
its  outcome,  unless  the  inflammatory  process  can  be 
arrested,  is  blindness  from  atrophy  of  the  optic  nerves. 

The  first  complaint  of  the  patient  is  of  a  "fogginess" 
of  vision,  as  though  he  w^ere  seeing  objects  through  a 
smoky  atmosphere.     A  common  accompanying  symp- 


3/6  PREVALENT    DISEASES    OF    THE     EYE. 

torn  is  recurrent  frontal  headache.  A  characteristic 
early  symptom,  to  be  determined  by  a  perimetric  exam- 
/  ination,  is  a  nearly  central  color  scotoma — an  area  ot 
red-green  blindness  extending  from  the  fixation  point 
to  the  normal  blind  spot.  Any  degree  of  impairment 
of  central  vision  may  be  present,  a  visual  acuteness  of 
one-fourth  to  one-tenth  normal  being  not  unusual  at 
the  time  medical  advice  is  sought.  The  fact  that  the 
failure  of  sight  is  very  gradual  probably  explains  this 
.  singular  circumstance. 

Although  in  exceptional  instances  the  disease  under 
consideration  is  produced  by  such  agents  as  nitrobenzol 
(used  in  the  manufacture  of  certain  explosives),  bi- 
sulphid  of  carbon  (employed  in  vulcanizing  rubber), 
arsenic,  lead,  iodoform,  etc.,  it  is  usually  caused  by 
tobacco  or  alcohol  or,  as  is  more  often  the  case,  by  the 
combined  action  of  the  two.  For  this  reason  it  is  en- 
countered much  more  frequently  in  males  than  in 
females.  The  habitual  smoker  and  the  habitual  dram- 
drinker  are  the  ones  in  whom  it  is  most  likely  to  develop. 
In  some  instances  it  has  been  observed  in  persons  whose 
employment  compelled  them  to  inhale  air  laden  with 
tobacco  dust,  as  in  tobacco  manufacturing  establish- 
ments. It  is  rarely  met  with  in  persons  under  thirty-five 
years  of  age. 

Although  the  intraocular  signs  of  chronic  retrobulbar 
neuritis  are  not  very  marked  or  characteristic,  the  oph- 
thalmoscope is  helpful  in  arriving  at  a  diagnosis.  In 
the  early,  the  inflammatory,  stage  of  the  disease  there 
is  usually  marked  hyperemia  of  the  optic  disc.  Later 
on,  when  the  stage  of  atrophy  is  reached,  the  disc  be- 
comes pale  and  perceptiblv  cupped,  and  the  lamina 
cribrosa  is  seen  with  too  great  distinctness,  these 
changes  commonly  being  more  marked  in  the  lower 


PLATE  IX. 


J'/,Llr  I   l>;.,hl  fyt 


-r     'iJi  : 


'"~-—if'^.// :'       i 


^^^*3*'**»«2S 


Skctions  of  the  Right  Optic  Nerve  of  Dr.  G.  E.  de  Schweinitz's 
Case  of  Tobacco  Amblyopia,  Showing   Degeneration  of  teie  Papil- 

LOMACULAR    BUNDLE;    WeIGERT'S    StAIN. 

Fig.  I. — Longitudinal  section  of  the  posterior  half  of  the  right  bulbus 
and  five  millimeters  of  the  optic  nerve. 

Figs.  2  and  3. — Transverse  sections  of  the  optic  nerve,  eight  and 
thirteen  millimeters,  respectively,  behind  the  globe. 

Figs.  4  and  5. — Transverse  sections  of  the  optic  nerve  in  the  region  of 
the  optic  foramen. 

Fig.  6. — Transverse  section  of  the  nerve  in  the  intracranial  region. 


DISEASES    OF    THE    OPTIC    NERVE.  377 

temporal  quadrant,  which  corresponds  with  the  situa- 
tion of  the  papillo-macular  fibers. 

The  prognosis,  especially  in  the  cases  which  are  due 
to  tobacco  and  alcohol,  is  not  unfavorable,  even  when 
vision  is  greatly  impaired,  if  the  atrophic  process  has 
not  already  progressed  too  far. 

Treatment. — The  most  important  feature  of  the  treat- 
ment is  the  absolute  withdrawal  of  the  toxic  agent  which' 
has  provoked  the  neuritis.  In  the  case  of  smokers  and 
dram-drinkers  total  abstinence  from  the  use  of  tobacco 
and  alcohol  must  be  insisted  upon.  In  addition  to  this, 
and  especially  during  the  inflammatory  stage,  indicated 
by  the  hyperemic  papilla,  moderate  doses  (g^j  to  ^t  o^  ^ 
grain)  of  biniodid  of  mercury  should  be  prescribed,  and 
in  combination  with  this  strychnin  should  be  given  in 
ascending  doses.  There  is  no  excuse,  in  my  judgment, 
for  administering  the  strychnin  hypodermically,  as 
some  authorities  advise.  Beginning  with  a  thirtieth  of 
a  grain,  given  three  times  a  day,  and  directly  after  ji^eals, 
the  dose  may  be  gradually  increased,  as  tolerance  is 
established,  until  finally  it  reaches  five  or  six  times  this 
amount.  It  has  not  been  my  experience,  in  a  single 
instance,  to  meet  with  the  cumulative  effect  which  some 
contend  is  liable  to  occur  from  the  prolonged  exhibition 
of  this  drug. 

Quinin  Blindness. — As  a  result  of  the  adminis- 
tration of  heroic  doses  of  quinin,  and  in  susceptible  in- 
dividuals of  doses  which  could  not  be  so  regarded,  pro- 
nounced impairment  of  vision,  at  times  complete  loss 
of  sight,  occasionally  is  produced.  Investigation  has 
shown  that  the  visual  disturbance,  which  is  usually  ac- 
companied by  deafness  and  marked  tinnitus,  is  due  to 
excessive  spasm  of  the  vessels  of  the  retina  and  optic 
nerve.     The  resulting  ischemia,  if  it  persists  for  a  con- 


^y^  PREVALENT    DISEASES   OE    THE    EYE. 

siderable  time,  may  give  rise  to  degeneration  of  the  gan- 
glion cells  and  nerve-fibers  of  the  retina  and  ultimately 
to  an  ascending  atrophy  of  the  optic  nerve,  as  Ward 
Holden  has  pointed  out.  Fortunately,  the  outcome  of 
these  cases  is  usually  not  so  serious,  the  blindness  often 
proving  to  be  transient,  and  normal  vision  being  re- 
gained, it  may  be  after  a  few  hours,  or,  perhaps,  not  until 
the  lapse  of  some  days.  While  the  blindness  persists 
the  pupils  are  widely  dilated  and  non-responsive  to  light. 
Not  infrequently  the  loss  of  sight  is  preceded  by  head- 
ache, unsteadiness  of  gait,  and,  in  some  instances,  by 
visual  hallucinations. 

Treatment  consists  in  inhalations  of  nitrite  of  amyl 
and  in  the  administration  of  nitroglycerin,  to  be  followed 
by  ascending  doses  of  strychnin.  The  giving  of  quinin 
should,  of  course,  be  stopped  at  once. 

Atrophy  of  the  Optic  Nerve. — Two  definite  types 
of  optic  nerve  atrophy  are  recognized — a  primary,  non- 
inflammatory atrophy,  which  is  usually  consequent 
upon  spinal  disease,  and  an  atrophy  consecutive  to  optic 
neuritis  or  retinitis.  With  the  ophthalmoscope  it  is 
usually  possible  to  distinguish  these  two  forms,  for 
although  in  each  the  optic  disc  is  pale,  or  conspicuously 
white  if  the  atrophy  is  advanced,  there  are  present  in  the 
post-neuritic  type  certain  definite  signs  of  the  precedent 
inflammation  which  are  wanting  in  the  primary  type. 
Clinically  the  two  forms  difi^er  in  that  while  the  prog- 
nosis is  grave  in  each,  it  is  more  entirely  hopeless  in 
primary  than  it  is  in  consecutive  atrophy.  The  progress 
of  the  former  also  is  slow^er,  and  in  it  both  eyes  are 
almost  always  involved,  whereas  the  latter  is  not  infre- 
quently unilateral. 

Primary,  simple,  or  non-inflammatory  atrophy 
of  the  optic  nerve    is   oftenest   encountered  in  tabes 


DISEASES    OF    THE    OPTIC    NERVE.  379 

dorsalis;  it  is  not  uncommon  also  in  the  general  paraly- 
sis of  the  insane,  and  it  may  be  due  to  syphilis, 
venereal  excesses,  diabetes,  or  the  toxic  action  of  certain 
drugs.  There  is  also  a  hereditary  form,  which  occurs 
almost  exclusively  in  males,  and  there  is  still  another 
form  which  is  produced  by  compression  of  the  nerve — 
as  by  the  growth  of  a  tumor,  periosteal  thickening  and 
the  like — either  within  the  cranium  or  within  the  orbit. 
As  has  been  said,  the  affection  is  almost  always  bilateral, 
the  cases  in  which  only  one  eye  is  involved  being  usually 
those  which  are  consequent  upon  orbital  disease. 

Among  the  earliest  symptoms  are  inability  to  dis- 
tinguish small  objects — as,  for  example,  the  letters  of  a 
printed  page — by  subdued  light,  diminution  or  loss  of 
color  perception,  and,  as  shown  by  the  perimeter,  con- 
centric, or  perhaps  quite  irregular,  contraction  of  the 
visual  fields.  Slowly  the  decline  of  vision  progresses, 
until  ultimately,  it  may  be  not  until  after  many  months, 
sight  is  completely  lost.  The  failure  of  vision  is  ac- 
companied by  expansion,  exceptionally,  in  certain 
spinal  affections,  by  contraction,  of  the  pupil,  and  by  its 
sluggish  response,  or  complete  lack  of  response,  to  light 
stimulation.  Especially  in  cases  of  tabetic  origin,  the 
Argyll-Robertson  symptom  is  observed — failure  of  the 
pupil  to  contract  to  light,  but  its  prompt  contraction 
when  accommodation  and  convergence  are  called  into 
play. 

The  ophthalmoscopic  signs  of  simple  atrophy — and 
in  no  case  of  suspected  optic  nerve  atrophy  should  an 
ophthalmoscopic  examination  be  omitted — are  very 
striking.  The  papilla,  at  first  only  slightly  pale,  grows 
progressively  whiter  as  the  nerve-fibers  atrophy  and  the 
fine  blood-vessels,  which  give  to  the  normal  papilla  its 
pinkish  color,  disappear.     At  the  same  time  its  outlines 


380  PREVALENT    DISEASES    OF    THE     EYE. 

remain  sharply  defined,  its  surface  becomes  more  or 
less  markedly  depressed,  and  the  lamina  cribrosa  is 
seen  with  too  great  distinctness,  and  not  over  a  limited 
area  only,  as  when  a  deep  phvsiological  cup  is  present, 
but  over  the  whole,  or  a  considerable  part,  of  the  disc 
(Fig.  144).  Accompanying  these  alterations  in  the 
nerve-head  there  is  commonly  some  diminution  in  the 
caliber  of  the  retinal  arteries;    but,  apart  from  this,  and 


Fig.   144. — Primary  atrophy  of  the  optic  nen'c  (Haab). 

in  striking  contrast  to  what  is  observed  in  post-neuritic 
or  post-retinitic  atrophy,  there  are  no  other  fundus 
changes — no  thinning  or  heaping  up  of  the  retinal  or 
choroidal  pigment.  In  tabes,  atrophy  of  the  optic 
nerve  is  often  an  early  symptom,  making  its  appear- 
ance before  the  occurrence  of  the  ataxia.  It  should, 
therefore,  always  be  sought  for  whenever  there  is  a 
suspicion  of  the  existence  of  this  affection. 


DISEASES    OF    THE    OPTIC    NERVE.  381 

Treatment  is  of  but  little  avail,  as  may  be  inferred 
from  what  has  been  said  as  to  the  irremediableness  of 
the  affection.  Strychnin,  in  increasing  doses,  should  be 
given  a  thorough  trial,  and  if  there  is  a  history  of  lues 
potassium  iodid  should  be  prescribed  in  full  doses. 
Galvanism  and  massage,  which  some  commend,  are 
of  little  or  no  value. 

Consecutive  Atrophy  of  the  Optic  Nerve  (In- 
flammatory Atrophy). — This  type  of  degeneration 
of  the  nerve  may  follow  any  one  of  the  several  forms 
of  optic  neuritis,  or  may  be  secondary  to  uncontrolled 
retinitis;  it  may  also  be  consequent  upon  embolism  or 
thrombosis  of  the  central  artery  of  the  retina  or  throm- 
bosis of  the  central  vein.  It  is  especially  prone  to  occur 
after  the  so-called  intraocular  forms  of  neuritis,  and  is 
less  common  after  retrobulbar  neuritis. 

The  subjective  symptoms  are  much  the  same  as  in 
primary  atrophy,  though  the  failure  of  sight  is  usually 
more  rapid,  and  the  affection  is  less  constantly  bilateral. 
The  pupil  is  dilated  and  responds  sluggishly,  or  not  at 
all,  to  light.  Apart  from  this,  the  eye  exhibits  no 
external  signs  of  disease. 

The  diagnosis  is  to  be  definitely  established  only  by 
an  ophthalmoscopic  examination.  The  fundus  changes 
differ  appreciably  from  those  seen  in  simple  atrophy. 
The  papilla  is  white,  but  its  margins  are  ill-defined, 
and,  owing  to  the  presence  of  newly  formed  connective 
tissue  resulting  from  the  precedent  inflammation,  it 
lacks  the  translucencv  observed  in  primary  atrophy,  and 
for  this  reason  the  lamina  cribrosa  is  not  seen.  The 
indistinctness  of  the  disc-margin  is  in  part  due  to  this 
same  cause  and  in  part  to  pigment  changes  in  the  ad- 
jacent retina.  The  retinal  vessels  upon  and  in  the 
neighborhood  of  the   papilla  are  frequently  bordered 


382  PREVALENT    DISEASES    OF    THE     EYE. 

by  white  streaks,  due  to  thickening  of  their  lymph- 
sheaths.  The  arteries  are  diminished  in  size,  the  veins 
for  a  considerable  time  often  distended  and  tortuous. 
When  the  atrophy  is  consequent  upon  retinitis,  the  pig- 
ment and  other  changes  usually  left  by  this  condition 
are  found  disseminated  over  the  eye-ground,  and  the 
retinal  vessels,  veins  as  well  as  arteries,  are  commonly 
much  diminished  in  caliber. 

The  prognosis  in  consecutive  atrophy  depends  in 
large  measure  upon  the  stage  which  the  atrophic  process 
has  reached  at  the  time  the  case  comes  under  observa- 
tion and  upon  the  nature  of  the  affection  primarily 
responsible  for  it.  If  the  inflammatory  process  is  still 
active,  and  the  nerve-fibers  are  suffering  from  the  com- 
pression of  exudates  the  absorption  of  which  it  may 
be  possible  to  bring  about,  much  may  be  hoped  for 
from  energetic  treatment.  On  the  other  hand,  if  the 
case  is  not  seen  until  a  considerably  later  period,  when 
the  inflammation  is  a  thing  of  the  past,  and  the  degen- 
eration of  the  nerve  is  advanced,  the  outlook  is  wholly 
unpromismg.  It  is  most  unpromising  also  when  the 
primary  affection  of  the  nerve  has  been  caused  by 
serious  intracranial  disease  or  by  such  intractable 
maladies  as  chronic  nephritis,  diabetes,  etc.,  or  has  fol- 
lowed degeneration  or  severe  inflammation  of  the  retina. 

Treatment. — This  must  depend  largely  upon  the 
conditions  existing  at  the  time  the  case  is  seen.  Po- 
tassium iodid  and  mercury  are  the  remedies  to  be  relied 
upon  to  promote  the  absorption  of  exudates,  and  relieve 
the  nerve  fibers  from  compression,  and  therefore  are  of 
greatest  value  when  given  at  an  earh'  stage  of  the  affec- 
tion. In  addition,  strychnin,  in  increasing  doses,  is 
indicated,  at  this  stage  as  well  as  at  a  later  period,  when 
it  is,  in  fact,  our  only  reliance. 


DISEASES    OF    THE    OPTIC    NERVE.  383 

Hemianopsia  (Hemiopia). — Hemianopsia  or  half- 
blindness,  a  serious  disturbance  of  vision,  sudden  in 
onset,  involving  both  eyes,  and  ot  most  unfavorable 
prognosis,  finds  its  explanation  in  the  semi-decussation 
of  the  optic  nerves.  When  the  nerve-fibers  of  each  optic 
tract  reach  the  chiasm,  it  will  be  remembered,  they  sep- 
arate into  two  bundles — an  outer  bundle  which  proceeds 
to  the  eye  of  the  same  side,  and  an  inner  bundle  which 
crosses  in  the  chiasm  and  proceeds  to  the  opposite  eye.  It 
will  be  remembered  also  that  the  non-decussating  fibers 
supply  the  outer  or  temporal  half  of  the  retina  of  the 
eye  to  which  they  go,  and  that  the  decussating  fibers  sup- 
ply the  inner  or  nasal  half.  As  a  consequence  of  this,  it 
is  evident  that  the  fibers  coming  from  the  right  side  of  the 
brain,  and  forming  the  right  optic  tract,  supply  the  right 
half  of  the  retina  of  each  eye,  that  is  to  say,  the  temporal 
half  of  the  retina  of  the  right  eye  and  the  nasal  half  of 
that  of  the  left  eye;  while  the  conditions  are  reversed 
as  to  the  fibers  coming  from  the  left  side  of  the  brain. 
From  this  it  is  further  evident  that  a  lesion,  for  example, 
of  the  right  optic  tract,  or  the  visual  centers  of  the 
right  half  of  the  brain  with  which  it  is  in  relation,  will 
destroy  the  perceptive  power  of  the  right  half  of  each 
retina,  causing  left-sided  blindness  or  loss  of  the  left 
half  of  the  visual  field  of  each  eye;  that  a  lesion  which 
affects  the  decussating  fibers  only  will  cause  blindness  of 
the  inner  or  nasal  half  of  each  retina,  with  loss  of  the  outer 
or  temporal  visual  field  of  each  eye,  and  that  one  which 
involves  only  the  non-decussating  fibers  will  affect  the 
outer  half  of  each  retina  and  result  in  blindness  of  both 
nasal  fields.  A  further  possibility  is  that  the  nerve- 
fibers  supplying  either  the  upper  or  the  lower  half  of  each 
retina  may  be  destroyed,  and,  as  a  consequence,  that 


3^4 


PREVALENT    DISEASES    OF    THE     EYE. 


the  lower  or  upper  half,  as  the  case  may  be,  of  the  visual 
field  of  each  eye  may  be  lost. 

All  of  these  forms  of  hemianopsia — which  a  study  of 
the  accompanying  illustration  (Fig.  145)  will  make  more 


Jfusculas  rec&is 
externus. 


Xolfo  OccipvtaZi^ 

Fig.   145. — Scheme  of  the  optic  tracts  (after  von  Monakow). 

easy  of  comprehension — are  met  with;  but  the  two  last- 
described,  known  respectively  as  hinasal  hemianopsia 
and  horizontal  hemianopsia,  for  obvious  reasons — be- 
cause a  lesion  which  shall    affect   the   non-decussating 


DISEASES    OF    THE    OPTIC    NERVE.  385 

fibers  at  each  extremity  of  the  chiasm,  without  involving 
the  decussating  fibers  lying  between  them,  or  one  which 
shall  destroy  only  the  fibers  lying  close  to  the  upper  or 
lower  surface  of  the  chiasm,  permitting  the  others  to  es- 
cape, must  necessarily  be  ot  rare  occurrence — are  very 
uncommon.  On  the  other  hand,  the  two  first-mentioned 
forms — that  in  which  the  right,  or  it  may  be  the  left, 
half  of  the  visual  field  oi  each  eye  is  lost,  known  as 
homonymous  lateral  hemianopsia,  and  that  in  which  both 
temporal  fields  are  lost,  known  as  bitemporal  hemian- 
opsia,— are  more  frequently  encountered,  and  demand 
fuller  consideration. 

Homonymous  Lateral  Hemianopsia. — This  variety 
of  hemianopsia,  in  which  there  is  loss  of  the  right 
or  left  half  of  each  visual  field,  is  the  one  oftenest 
met  with.  It  may  be  caused  by  a  lesion  of  either  cor- 
tical visual  center  or  by  one  which  produces  a  break 
in  the  visual  tract  anywhere  between  this  center  and  the 
optic  chiasm,  that  is,  in  the  optic  radiations,  in  the  pri- 
mary visual  ganglia,  or  in  the  optic  tract  itself.  Among 
the  conditions  apt  to  produce  such  a  lesion  may  be 
mentioned  hemorrhage,  embolism,  softening,  abscess, 
intracranial  syphilis,  and  the  pressure  of  a  tumor. 

The  visual  disturbance,  which  may  be  preceded  by 
headache  and  accompanied  by  giddiness  and  nausea, 
is  commonly  sudden  in  onset,  and  is  at  times  attended 
by  other  evidences  of  serious  brain  injury,  such  as  hemi- 
plegia, aphasia,  etc.  The  loss  of  vision  in  the  affected 
half  of  the  field  is  usually  complete;  but  fortunately 
the  macular  region  nearly  always  escapes  serious  in- 
volvement, and  good  central  vision  is  retained.  This 
is  due  to  the  fact — doubtless  a  result  of  the  action  of  the 
law  of  the  survival  of  the  fittest— that  this  most  essential 
and  most  highly  specialized  portion  of  the  retina  is 
25 


386  PREVALENT    DISEASES    OF    THE     EYE. 

supplied  by  fibers  from  both  sides  of  the  brain.  Be- 
cause of  the  one-sided  character  of  the  blindness,  the 
patient  frequently  imagines  that  one  eye  only  is  affected, 
and  is  much  surprised  when  made  aware  of  the  true  con- 
dition. At  first  he  experiences  much  inconvenience 
from  the  curtailment  of  his  field  of  vision,  but  in  time 
he  becomes  less  conscious  of  the  defect.  As  might  be 
supposed,  the  afi^ection  is  more  common  in  advanced 
life,  when  the  walls  of  the  blood-vessels  are  undergoing 
degenerative  changes.  For  some  time  after  the  onset 
of  hemianopsia  the  ophthalmoscope  shows  no  alter- 
ation in  the  papilla,  but  later  evidences  of  partial  atro- 
phy may  make  their  appearance. 

Attacks  of  transient  hemianopsia,  lasting  usually  for 
but  a  few  moments,  and  of  very  different  import  from 
the  serious  affection  under  consideration,  are  not  un- 
common. They  are  doubtless  due  to  some  temporary 
disturbance  m  the  circulation  of  the  visual  centers,  and, 
in  my  experience,  are  oftenest  brought  on  by  eye-strain 
from  refractive  or  muscular  faults. 

Bitemporal  Hemianopsia. — This  form  of  half-vision, 
of  much  less  frequent  occurrence  than  the  one  just  de- 
scribed, is  produced  by  a  lesion  involving  the  central 
portion  of  the  chiasm,  and  injuring  the  decussating 
fibers  only.  It  may  be  the  result  of  hemorrhage,  aneu- 
rism, syphilis,  of  a  tumor,  or  of  a  fracture  of  the  base 
of  the  skull.  It  also  occurs  in  acromegaly  as  a  conse- 
quence of  enlargement  of  the  pituitary  body.  The  dis- 
turbance of  vision  is  very  annoying  because  of  the  great 
circumscription  of  the  lateral  fields. 

In  bitemporal  as  well  as  in  binasal  hemianopsia  the 
prognosis  is  somewhat  more  favorable  than  in  the  ho- 
monymous form.  Homonymous  hemianopsia  has  little 
or  no  localizing  value,  as  is  evident  from  what  has  been 


DISEASES    OF    THE    OPTIC    NERVE.  38/ 

said  as  to  the  various  conditions  which  may  give  rise  to 
it;  but  the  bitemporal  and  binasal  forms  have,  since 
they  indicate  that  the  lesion  is  in  the  neighborhood  of 
the  chiasm.  The  importance  in  all  cases  of  cerebral 
disease  of  measuring  the  visual  fields,  to  determine 
whether  or  not  hemianopsia  is  present,  is  manifest. 

The  treatment  of  the  several  varieties  of  hemianopsia 
is  usually  without  avail.  The  prognosis,  as  a  rule,  is 
more  promising  in  the  cases  of  syphilitic  origin.  Po- 
tassium iodid  and  mercury  are  the  remedial  agents  from 
which  most  is  to  be  hoped. 


CHAPTER  XI. 

ANOMALIES  OF  REFRACTION  AND  ACCOMMO- 
DATION. 

ANOMALIES  OF  REFRACTION. 
It  is  not  the  purpose  of  this  chapter  to  encourage  the 
general  practitioner  to  undertake  the  determination  and 
correction  of  the  refractive  anomahes  of  the  eye,  or  to 
teach  him  how  to  do  this.  On  the  contrary,  one  of  its 
purposes,  at  least,  is  to  impress  upon  him,  what  so 
many  physicians  fail  to  realize,  that  there  is  no  branch 
of  ophthalmic  practice  which  more  imperatively  de- 
mands the  skill  and  training  of  the  specialist  than  does 
this  matter  of  the  measurement  and  correction  of  the 
refractive  errors  and  muscular  faults  of  the  eyes.  There 
are,  indeed,  few  misconceptions  which  call  for  more  vig- 
orous combating  than  the  belief,  so  common  among 
medical  practitioners  who  have  paid  but  little  attention 
to  diseases  of  the  eyes,  that  the  adjustment  of  glasses  is  a 
trivial  matter  which  may  be  undertaken  by  any  physi- 
cian who  may  have  provided  himself  with  test-cards  and 
a  trial  case,  or  may  be  safely  left  to  the  hap-hazard 
methods  of  the  nearest  vender  of  spectacles,  or  to  the 
jeweler's  clerk  who,  after  a  few  weeks  of  instruction  in 
an  "optical  college,"  announces  himself  as  an  "exam- 
ining, "or  an  "ophthalmic,"  optician.  How  much  harm 
the  community  suffers  from  the  pretentious  ignorance 
of  such  tyros  it  would  be  difficult  to  estimate.  Let  the 
general  practitioner  but  bear  in  mind  that  the  vender 
of  spectacles — the  optician — has  a  knowledge  of  the  eye 


ANOMALIES    OF    REFRACTION.  389 

and  its  diseases  about  equivalent  to  that  which  the  ven- 
der of  drugs — the  apothecary — has  of  general  medicine, 
and  he  will  not  be  so  apt  to  fall  into  the  error  which  I 
have  tried  to  emphasize.  Not  only  the  welfare  of  the 
eye,  it  should  be  borne  in  mind,  but  in  many  instances 
the  general  well-being  of  the  individual  hinges  upon 
the  accuracy  with  which  these  optical  and  muscular 
faults  are  corrected. 

How  important  a  role  errors  of  refraction  play  in  the 
causation  of  many  serious  diseases  of  the  eye  few  who 
have  not  made  a  special  study  of  the  subject  realize. 
Frequent  reference  has  already  been  made  to  this  fact, 
and  in  treating  of  the  etiology  of  cataract,  of  glaucoma, 
of  choroido-retinitis,  of  chronic  conjunctivitis,  and  of 
blepharitis  marginalis  much  stress,  it  will  be  recalled, 
was  laid  upon  the  important  influence  exerted  by  accom- 
modative strain  in  the  production  of  these  diseases. 
From  my  own  observation,  I  am  well  satisfied  that  even 
such  affections  as  albuminuric  and  diabetic  retinitis, 
syphilitic  choroido-retinitis,  and  the  inflammatory  pro- 
cesses of  the  eye  dependent  upon  a  rheumatic  diathesis 
are,  at  least,  unfavorably  influenced,  if  not  in  some  in- 
stances actually  precipitated,  by  the  strain  caused  by 
uncorrected  refractive  and  muscular  anomalies.*  That 
not  only  strabismus  but  many  less  obvious  disturbances 
in  the  ocular  muscle-balance  are  largely  dependent  upon 
errors  of  refraction  is,  of  course,  w^ell  established. 

As  to  the  importance  of  the  role  played  by  e)'e-strain 
in  the  production  of  other  disorders  than  those  of  the  eye 

*  This  statement  may  seem  extravagant;  but  it  will  not  be  denied 
that  in  such  disorders  it  is  the  tissues  the  resisting  powers  of  which 
are  poorest  that  are  most  apt  to  suffer.  And,  unquestionably,  this 
is  the  condition  of  the  internal  tunics  of  an  eye  which,  as  a  result  of 
long-continued  accommodative  strain,  are  already  in  a  state  border- 
ing upon  inflammation. 


390  PREVALENT    DISEASES    OF    THE    EYE. 

itself  there  can  be  no  question;  though  it  must  be  ad- 
mitted that,  as  to  this,  there  has  been  much  exaggeration. 
The  claim,  seriously  put  forward,  that  sterility,  men- 
strual disorders,  habitual  constipation,  epilepsy,  etc., 
are  frequently  due  to  refractive  errors,  and  may  be 
cured  by  their  correction,  is,  of  course,  absurd;  but, 
on  the  other  hand,  there  can  be  no  doubt  that  such  errors 


Fig.  146. — Types  of  spherical  lenses  prescribed  in  ametropia  and  pres- 
byopia: I,  Biconvex  lens;  2,  plano-convex  lens;  3,  concavo-convex  lens, 
convergent  meniscus;  4,  biconcave  lens;  5,  plano-concave  lens;  6,  convexo- 
concave  lens,  divergent  meniscus  (de  Schweinitz). 

are  a  common  cause  of  headache,  of  neurasthenia,  of 
vertigo,  of  insomnia,  of  somnolency,  and  of  disturbance 
of  mental  concentration;  that  thev  are  a  less  frequent 
cause  of  nausea,  indigestion,  tinnitus  aurium,  and 
chorea,  especially  of  the  facial  muscles;  and  that,  excep- 
tionally, they  exert  a  by  no  means  unimportant  influ- 
ence upon  epilepsy. 


ANOMALIES    OF    REFRACTION.  39I 

Before  describing  the  refractive  errors,  it  will  not  be 
amiss  to  speak  of  some  of  the  prevalent  misconceptions 
regarding  these  errors  and  concerning  the  indications 
for  glasses  and  their  influence  upon  sight  (Fig.  146). 

In  the  first  place,  it  is  a  mistake  to  suppose  that  errors 
of  refraction — which  are  really  faults  in  the  conforma- 
tion of  the  eye — may  be  "outgrown,"  or  may  be  gotten 
rid  of  by  any  therapeutic  procedure,  such  as  prolonged 
rest,  systematic  exercise  of  the  eyes,  massage,  etc., 
and,  as  a  corollary  of  this,  that  the  wearing  ot  glasses 
should  be  regarded  as  a  dernier  ressort. 

In  the  next  place,  it  is  as  great  a  mistake  to  imagine 
that  glasses  are  injurious  to  the  eyes,  that  they  "weaken 
the  sight,"  as  the  common  expression  is,  and  that  if  their 
use  is  begun  in  early  life  a  time  may  come  when  it  will  not 
be  possible  to  find  lenses  that  will  afford  the  needed  help. 
If  glasses  really  are  needed,  the  eves  soon  learn  to  accept 
the  help  which  they  give,  and,  of  necessity,  become  de- 
pendent upon  this  help;  but  so  far  from  injuring  the 
eyes  or  "weakening  the  sight,"  the  effect,  of  course,  is 
exactly  the  reverse.  Furthermore,  though  glasses  of 
considerable  strength  be  prescribed,  as  is  often  neces- 
sary, for  children  not  yet  in  their  "teens,"  there  need  be 
no  fear,  though  they  live  to  be  octogenarians,  that  the 
required  lenses  can  not  be  easily  supplied.  In  a  word, 
the  popular  prejudice  against  the  wearing  of  glasses, 
and  especially  against  their  use  by  young  persons,  is 
entirely  without  warrant.  Unquestionably,  from  a 
cosmetic  point  of  view  objection  may  be  urged  against 
their  use;  but  this,  of  necessity,  must  give  way  to  con- 
siderations of  greater  weight. 

Again,  it  should  be  remembered  that  glasses  are  not 
given  solely  with  a  view  to  making  vision  more  acute. 
As  a  matter  of  fact,  in  many  instances,  especially  in 


392  PREVALENT    DISEASES    OF    THE     EYE. 

early  life,  there  may  be  urgent  need  for  them,  and  yet 
normal  acuteness  of  vision,  for  both  near  and  distant 
objects,  may  exist.  Under  such  circumstances,  and 
this  applies,  of  course,  to  many  cases  in  which,  besides, 
they  do  render  vision  more  acute,  they  are  demanded  for 
the  purpose  of  relieving  the  strain  which  the  optical 
error  imposes  upon  the  accommodative  apparatus.  In- 
deed, the  very  fact  that  young  eyes,  m  spite  of  the  exist- 
ence of  marked  refractive  errors,  often  do  see  sharply  is 
evidence  of  the  great  tension  under  which  they  perform 
their  office.  It  may  be  well  to  add  that  though  glasses 
unquestionably  tend  to  prevent  the  increase  of  certain 
refractive  errors — myopia  especially — it  is  not  to  be 
expected  that  they  will  cure  the  optical  defect,  for  which 
they  are  prescribed.  For  this  reason,  the  hope  can 
seldom  be  held  out  that  after  a  time  the  eves  w411  not 

J 

need  their  assistance.  In  exceptional  instances  this  may 
happen,  as,  for  example,  in  low  grades  of  hypermetropia 
or  astigmatism,  when  the  asthenopic  symptoms  have 
manifested  themselves  for  the  first  time  after  an  illness 
which  has  lowered  the  general  tone  of  the  system; 
but  such  instances,  it  is  well  to  remember,  are  distinctly 
exceptional. 

Finally,  it  should  be  stated  that  not  every  eye  needing 
the  help  of  glasses  makes  a  direct  appeal  for  their  aid. 
Not  infrequently,  when  the  remote  consequences  of  eye- 
strain are  pronounced,  there  may  be  little  or  no  com- 
plaint of  the  eyes  themselves.  Therefore  one  should 
not  be  too  ready  to  conclude  that  persistent  headache, 
obscure  neurasthenic  symptoms,  etc.,  can  not  be  due 
to  eye-strain,  because  there  is  little  or  no  asthenopia. 
In  illustration  of  this,  a  case  may  be  mentioned  which 
came  under  my  observation  not  long  since.  A  young 
woman,  who  was  unconscious  of  anything  being  amiss 


ANOMALIES    OF    REFRACTION. 


393 


with  her  eyes,  frequently  awakened  in  the  middle  of 
the  night  with  attacks  of  pronounced  vertigo.  Her 
physician,  not  being  able  to  discover  a  cause  for  these 
attacks  or  a  means  of  relieving  them,  thought  of  the 
possibility  of  their  being  dependent  upon  eye-strain, 
and  sent  her  to  me  for  advice.  A  moderate  amount  of 
astigmatism  was  discovered,  and  correcting  glasses 
were  prescribed,  with  some  misgivings  as  to  the  result; 
but  after  they  had  been  worn  a  very  short  time  the  ver- 
tiginous attacks  ceased. 

Emmetropia. — In  order  to  a  proper  understanding  of 
the  refractive  errors  of  the  eye  one  should  have  a  clear 
conception  of  what  constitutes  an  optically  normal,  or, 


Fig.   147. — Diagram  of  emmetropic  eye. 

as  it  is  called,  an  emmetropic  eye.  An  eye  is  said  to  be 
emmetropic  when  it  is  so  constructed,  when  the  focal 
length  of  its  system  of  lenses  with  reference  to  the  dis- 
tance between  the  cornea  and  the  retina  is  such,  that, 
with  the  accommodative  apparatus  at  rest,  parallel  rays 
of  light,  those  coming  from  distant  objects,  are  brought 
to  a  focus  exactly  upon  the  retina  (Fig.  147).  In  such  an 
eye,  it  will  be  seen,  accommodative  effort  is  required 
only  when  near  objects,  the  light  from  which  reaches  the 
eye  in  divergent  pencils,  are  regarded,  since  sharp  im- 
ages of  distant  objects  are  projected  upon  the  retina 
without  action  upon  the  part  of  the  ciliary  muscle.  An 
emmetropic  eye,  it  should  be  added,  is  not  necessarily  a 


394  PREVALENT    DISEASES    OF    THE     EYE. 

sharp-seeing  eye;  indeed,  it  may  be  blind,  for  example, 
from  atrophy  of  the  optic  nerve;  but,  however  this  may 
be,  it  is  at  all  events  one  that  is  normal  from  the  optical 
point  of  view. 

Ametropia. — This  term,  which  is  opposed  to  em- 
metropia,  denotes  a  departure  from  the  normal  in  the 
optical  construction  of  the  eye.  If  from  any  fault  in  the 
conformation  of  the  eye  sharp  images  of  distant  ob- 
jects are  not  formed  upon  the  retina,  or  are  so  formed 
only  by  an  effort  of  accommodation,  such  an  eye  is  ame- 
tropic.  The  term  is  a  general  one,  and  under  it  are  in- 
cluded all  the  optical  errors,  all  the  refractive  faults,  of 
the  eye.  If,  for  example,  the  lens  system  has  an  abnor- 
mally short  focal  length,  while  the  eyeball  is  of  normal 
dimensions,  or  if  the  focal  length  of  the  lens  system  is 
normal,  while  the  eyeball  is  elongated  in  its  antero-pos- 
terior  diameter,  that  form  of  ametropia  which  is  known 
as  myopia,  or  short-sightedness,  results.  If,  on  the  con- 
trary, the  focal  length  of  the  lens  system  is  longer  than 
it  should  be,  without  a  corresponding  elongation  of  the 
eyeball,  or  if  the  eye  is  preternaturally  flat,  without  a 
compensating  increase  of  its  refractive  power,  there  will 
result  the  type  of  ametropia  known  as  hypermetropia, 
or  far-sightedness.  If,  again,  there  is  a  lack  of  sym- 
metry in  the  curvature  of  the  cornea  or  the  lens,  or  if  the 
latter  sets  obliquely  with  reference  to  the  visual  axis,  so 
that  the  rays  of  light  entering  the  eye  are  not  focused 
accurately  at  any  point,  we  shall  have  still  another 
form  of  ametropia,  which  we  call  astigmatism. 

Each  of  these  refractive  faults,  which  are  of  common 
occurrence,  and  which  in  certain  important  respects 
differ  radically  in  their  essential  nature,  in  their  mode 
of  origin,  and  in  their  clinical  course,  has  its  character- 
istic shortcomings,  which  will  be  considered  presently. 


ANOMALIES    OF    REFRACTION.  395 

Hypermetropia  (Far-sightedness).  —  This  type 
of  refractive  error,  which  very  generally  is  of  con- 
genital origin,  is  the  most  prevalent  of  all  the  optical 
defects  of  the  eye.  Indeed,  it  is  so  prevalent  that  it  is  a 
question  whether  the  normal  eye  is  not  one  that  is 
slightly  hypermetropic — that  is,  when  its  accommoda- 
tion is  paralyzed  by  a  cycloplegic — rather  than  exactly 
emmetropic.  It  goes  without  saying,  therefore,  that 
the  very  low  grades  of  hypermetropia  are,  as  a  rule,  of 
little  moment,  and  seldom  require  correction. 

The  fault  of  the  hypermetropic  eye  is  that  it  is  in- 
capable of  focusing  upon  the  retina  even  parallel  rays  of 
light,  without  an  effort  of  accommodation.  The  out- 
come of  this  is  that  so  long  as  the  eyes  are  in  use  the 
ciliary  muscle  is  never  at  rest.  But  this  is  not  the  whole 
task  imposed  upon  the  hypermetropic  eye.  When  it  is 
employed  in  near  vision,  its  accommodative  apparatus 
must  do  double  duty;  its  ciliary  muscle  must  do  what  is 
required  of  the  ciliary  muscle  of  the  emmetropic  eye 
plus  the  effort  which  it  necessarily  puts  forth  to  secure 
clear  distant  vision.  Whether,  under  such  circum- 
stances, the  muscle  must  perform  only  considerably 
more  work  than  is  required  of  it  under  normal  con- 
ditions, or  twice  or  three  times  as  much,  depends  upon 
the  grade  of  the  hypermetropia.  Indeed,  if  the  refrac- 
tive fault  is  excessive,  and  the  same  is  true  with  lower 
degrees  of  hypermetropia  when  the  power  of  accommo- 
dation has  been  partly  lost  through  advancing  age,  it 
may  prove  unequal  to  the  task  imposed  upon  it,  and 
as  a  result  there  will  be  indistinctness  of  vision  for  both 
far  and  near  objects.  Such  a  condition  is  known  as 
absolute  or  no n- facultative  hypermetropia,  while  that  in 
which  clear  vision  is  obtained  through  the  action  of  the 
ciliary  muscle  is  denominated  facultative  hypermetropia. 


396  PRKVALENT    DISEASES    OF    THE     EYE, 

It  is  this  ever-present  strain  upon  the  accommodative 
apparatus,  greatly  increased  when  the  eyes  are  em- 
ployed in  near  vision,  that  gives  rise  to  the  asthenopia, 
headache,  blepharitis  marginalis,  and  the  intermittent 
indistinctness  of  vision  which  are  so  frequently  observed 
in  hypermetropia  of  considerable  degree.  And  it  is  by 
relieving  this  strain,  by  doing  for  the  eyes  what  they 
strive  to  do  for  themselves  at  such  cost,  that  glasses 
afford  in  this  condition  the  complete  relief  they  in- 
variably do. 

But  there  is  still  another  difficulty  with  which  the 
hypermetrope  has  to  contend.  In  emmetropia  there  is 
a  constant  harmony  between  the  effort  of  accommoda- 
tion and  the  effort  of  convergence  of  the  visual  axes, 
between  the  stimulus  to  action  sent  by  the  brain  to  the 
ciliary  muscles  and  to  the  internal  recti  muscles.  In 
distant  vision  both  sets  of  muscles  are  completely  re- 
laxed; in  near  vision  both  act  in  unison,  a  convergence 
for  twelve  inches,  as  in  reading,  for  example,  being  ac- 
companied by  a  corresponding  accommodative  effort. 
In  hypermetropia  this  harmony  is  radically  disturbed — 
accommodation  is  always  and  necessarily  in  excess  of 
convergence.  In  regardmg  distant  objects,  it  clear 
vision  is  to  be  had,  the  ciliary  muscles,  as  has  been  ex- 
plained, must  act,  while,  if  binocular  vision  is  to  be 
maintained,  the  internal  recti  muscle  must  remain  qui- 
escent. In  near  vision  the  difficulty  is  the  same,  the 
ciliary  muscles  must  put  forth  a  much  greater  effort 
than  is  required  of  the  interni.  In  a  word,  the  effort 
to  annul  the  normal  relation  between  accommodation 
and  convergence,  to  secure  sharp  vision  and  at  the  same 
time  to  maintain  binocular  fixation,  is  one  of  the  hyper- 
metrope's  most  trying  tasks. 

It  is  matter  for  little  surprise,  then,    that    the    hy- 


ANOMALIES    OF    REFRACTION.  397 

permetrope  should  elect,  not  infrequently,  to  rid  him- 
self of  this  task  by  a  sacrifice  of  binocular  vision;  that, 
in  order  to  restore  the  harmony  between  accommodation 
and  convergence,  he  should  permit  one  eye  to  squint. 
In  his  disposition  to  do  this  is  to  be  found  the  explana- 
tion of  the  occurrence  of  convergent  strabismus  in  hyper- 
metropia.  As,  however,  many  hypermetropes  do  not 
squint,  it  is  manifest  that  there  are  other  factors  which 
influence  the  development  ot  this  fault.  Among  those 
tending  to  favor  its  occurrence  may  be  mentioned  insuf- 
ficiency of  the  external  recti  muscles  and  subnormal  ac- 
commodative power;  while  it  is  manifest  that  insuffici- 
ency of  the  internal  recti  muscles  and  a  power  of  accom- 
modation above  the  normal  must  have  the  contrary 
effect.  Still,  beyond  question,  by  far  the  most  potent 
factor  in  the  causation  of  non-paralytic  convergent 
squint,  as  Donders  taught  us,  is  hypermetropia,  and  for 
the  reasons  just  set  forth. 

It  has  been  stated  already  that  hypermetropia  is 
nearly  always  a  congenital  anomaly,  and  that  it  consists 
either  in  an  abnormal  flatness  of  the  eyeball  or  in  a  lack 
of  refractive  power  in  the  lens  system  of  the  eye.  The 
first-mentioned  type,  in  which  the  antero-posterior  axis 
of  the  eye  is  shorter  than  it  should  be,  is  the  more  com- 
mon form,  and  is  known  as  axial  hypermetropia  (Fig. 
148).  The  type  in  which  there  is  a  lack  of  power  in  the 
refractive  media,  the  cornea  or  lens,  or  both,  being  less 
convex  than  normal,  is  known  as  curvature  hyperme- 
tropia,  and  is  not  only  less  common  but  is  less  uniformly 
congenital  in  origin,  since  it  may  be  acquired  through 
flattening  of  the  cornea  consequent  upon  inflammation, 
especially  inflammation  attended  by  loss  of  tissue. 

Congenital  hypermetropia,  it  should  be  clearly  under- 
stood, is  not  a  pathological  condition;  it  is  simply  a 


39^  PREVALENT    DISEASES    OF    THE    EYE. 

fault,  often  an  inherited  fault,  in  the  conformation  of  the 
eye.  It  is  also  a  fault  which  does  not  increase  in  degree; 
indeed,  in  early  life,  it  often  diminishes  appreciably,  but 
if  it  be  considerable  in  amount  its  disappearance  is  not 
to  be  looked  for. 

The  ill  consequences  of  hypermetropia,  if  the  defect  is 
of  high  grade,  manifest  themselves  very  early  in  life,  as 
soon,  indeed,  as  the  child  begins  to  use  the  eyes  in  re- 
garding small  objects,  as  in  looking  at  picture  books  or 
in  learning  to  read.  There  is  usually  no  complaint  of 
the  eyes,  but  it  is  seen  that  the  child  has  difficulty  in  dis- 


Fig.   148. — Diagram  of  axial  hypermetropia. 

tinguishing  small  letters,  and  it  is  at  this  time  that  the 
squint,  if  it  is  to  occur,  is  apt  to  develop. 

If  the  hypermetropia  be  non-facultative,  if  it  be  of  so 
high  a  degree  that  sharp  vision  can  not  be  mamtained 
even  by  the  greatest  effort  which  the  accommodation 
can  put  forth,  the  condition  frequently  simulates,  and  is 
mistaken  for,  myopia  of  high  grade.  The  child  holds 
the  printed  page  very  close  to  the  eyes,  since  in  this  way 
a  considerably  larger  retinal  image  is  obtained,  which 
more  than  offsets  the  increased  blurring.  If  the  defect 
be  less  pronounced,  it  may  give  rise  to  no  inconvenience 
until  the  child  is  old  enough  to  spend  more  time  in 
study,  when  the  appearance  of  asthenopia,  headache, 
and,  not  improbably  blepharitis,   may   be  looked  for. 


ANOMALIES    OF    REFRACTION,  399 

If  of  Still  lower  grade,  its  existence  may  be  unsuspected 
until,  with  the  failure  of  accommodation  consequent 
upon  increasing  years,  it  manifests  itself  through  un- 
comfortable and  defective  near  vision  and  through  the 
need,  at  an  exceptionally  early  age,  of  presbyopic 
glasses. 

Treatment. — It  is  evident,  from  what  has  already  been 
said,  that  the  whole  treatment  of  hypermetropia  is  com- 
prised in  the  careful  adjustment  of  glasses.  With  suit- 
able glasses  the  hypermetropic  eye  is  relieved  of  all 
strain,  and  is  capable  of  doing  the  work  which  the  nor- 


Fig.  149. — Correction  of  hypermetropia  by  a  convex  glass.  The  lens  L 
gives  to  parallel  rays  a  convergence  toward  the  point  R';  they  will  conse- 
quently be  united  upon  the  retina  R  without  an  effort  of  accommodation 
(de  Schweinitz). 


mal  eye  does  without  assistance  (Fig.  149).  There 
need  be  no  fear  of  ill  consequences,  therefore,  in  per- 
mitting the  young  hypermetrope,  with  his  refractive 
error  corrected,  to  pursue  his  studies  as  others  do,  or  to 
adopt  any  vocation  in  life  that  may  be  thought  desir- 
able. 

Whether  he  should  be  required  to  wear  the  glasses 
constantly,  in  far  as  well  as  in  near  vision,  will  depend 
largely  upon  the  degree  of  the  refractive  fault,  but  in  no 
small  measure,  also,  upon  his  power  of  accommodation 
and  upon  the  relative  strength  of  the  external  and  inter- 


400  PREVALENT    DISEASES    OF    THE     EYE. 

nal  recti  muscles.  Theoretically,  it  would  appear  that 
the  glasses  should  be  worn  constantly;  but,  practically, if 
the  fault  is  not  too  pronounced,  complete  relief  is  often 
obtained  by  their  use  in  near  vision  only.  It  follows  that 
in  determining  the  course  to  be  pursued  the  muscle  bal- 
ance for  both  far  and  near  vision  should  be  tested  with 
the  same  care  as  the  refractive  error.  The  same  consid- 
erations should  influence  one  also  in  decid.ng  upon  the 
strength  of  the  glasses  to  be  prescribed  in  any  particular 
case.  If  the  accommodation  is  active,  and  if  the  exter- 
nal recti  muscles  are  relatively  strong  as  compared  with 
the  internal  recti,  a  very  considerable  part  of  the  hyper- 
metropia  may  be  left  uncorrected;  w^hile,  on  the  other 
hand,  if  the  power  of  accommodation  is  poor  and  the 
external  recti  muscles  relatively  weak,  glasses  which 
give  full  or  nearly  full  correction  may  be  called  for  to 
insure  complete  relief. 

The  practice  followed,  especially  in  this  country,  by 
many  distinguished  oculists  of  prescribmg  glasses  which 
correct  the  total  refractive  error  as  revealed  by  a  cyclo- 
plegic,  without  regard  to  the  muscle  balance,  or,  in  other 
words,  without  reference  to  the  ability  of  the  eyes  to  help 
themselves,  is,  in  my  judgment,  unwarrantable,  since  it 
not  only  fails  to  take  account  of  the  fact  that  a  low  de- 
gree of  hypermetropia  is  hardly  to  be  regarded  as  an 
abnormal  condition,  but,  by  giving  the  eyes  more  help 
than  is  called  for,  it  disturbs  too  radically  the  established 
relation  between  accommodation  and  convergence,  and 
thus  substitutes  for  a  difficultv  of  one  sort  a  difficultv  of 
another  sort,  which  is  nearly  as  intolerable.  Moreover, 
it  is  objectionable  because  it  renders  the  eyes  more  abso- 
lutely helpless,  more  completely  dependent  upon  glasses, 
than  is  necessary. 

The  older  practice  of   correcting  only   that    part  of 


ANOMALIES    OF    REFRACTION.  4QI 

the  hypermetropia  which  is  manifcst^'^  that  is  to  say, 
the  part  which  can  be  made  evident  without  the  em- 
ployment of  a  cycloplegic,  provided  this  affords  a  normal 
muscle-balance  in  both  distant  and  near  vision,  I  can  not 
but  regard  as  a  much  more  rational  procedure.  Not  to 
be  misunderstood,  it  may  be  well  to  add  that  it  is  to  the 
considerably  greater  amount  of  hypermetropia  that  can 
be  rendered  manifest  by  painstaking  binocular  testing, 
and  not  to  the  less  amount  discoverable  when  the  eyes 
are  tested  separately,  that  reference  is  had  in  this  state- 
ment. Before  resort  to  the  binocular  test  the  mani- 
fest fault  of  each  eye  should,  of  course,  be  carefully 
determmed. 

With  the  gradual  failure  of  accommodation  that 
comes  with  increasing  age  the  ill  consequences  of  un- 
corrected hypermetropia  become  more  and  more  pro- 
nounced. Thus  it  happens  that  a  hypermetropia 
which  has  caused  no  inconvenience  in  childhood  may 
become  very  troublesome  with  the  passing  of  youth; 
for  it  must  be  remembered  that  the  power  of  accommo- 
dation begins  to  decline  very  early  in  life,  and  that  even 
a  child  ten  or  fifteen  years  of  age  has  already  lost  a  part 
of  the  ability  to  focus  the  eyes  which  it  possessed  when 
it  was  several  years  younger.  From  this  it  follows, 
other  things  being  equal,  that  the  need  for  glasses  in- 
creases with  the  age  of  the  hypermetrope,  and  that  as 
he  grows  older  he  will  not  only  require  a  fuller  correction, 
but  will  more  surely  need  to  wear  glasses  in  far  as  well 
as  in  near  vision.  This  increasing  dependence  upon 
glasses  need  give  rise  to  no  anxiety  for  the  future,  how- 
ever; for,  with  suitable  lenses,  his  eyes  will  continue  to 

*  The  manifest  hypermetropia  is  indicated  by  the  strongest  convex 
glass  with  which  sharp  distant  vision  can  be  maintained,  without,  of 
course,  a  cycloplegic  being  employed. 
26 


402  PREVALENT    DISEASES    OF    THE     EYE. 

serve  him  as  well  as  though  they  had  from  the  first  been 
free  from  refractive  fault.  If,  however,  his  error  of  re- 
fraction has  not  been  recognized,  or  if,  having  been  ad- 
vised to  wear  glasses,  as  not  infrequently  happens,  he 
has  disregarded  the  advice,  it  will  be  matter  for  little  sur- 
prise if  the  years  of  strain  to  which  his  eyes  have  been 
subjected  should  sooner  or  later  give  rise  to  serious 
consequences,  such  as  choroido-retinitis  or,  possibly, 
glaucoma  or  cataract. 

From  what  has  been  said  as  to  the  manner  in  which 
convergent  squmt  arises  in  hypermetropia,  it  is  evident 
that  w^e  have  in  glasses  a  very  efficient  means  of  pre- 
venting this  deformity,  and,  in  some  instances,  even  of 
correcting  it  after  it  has  become  established.  Indeed, 
it  is  safe  to  say  that  it  might  be  prevented  in  almost 
I  every  instance,  if  the  refractive  error  could  be  corrected 
soon  enough.  The  practical  difficulty  in  the  way  of 
doing  this  is  the  very  early  age — when  the  wearing  of 
glasses  is  almost  out  of  the  question— at  which  the  squint 
commonly  develops.  Still,  it  is  surprismg  how  little 
difficulty  is  experienced  in  inducing  a  child  that  is  de- 
cidedly hypermetropic,  though  it  may  be  only  three  or 
four  years  old,  to  wear  glasses;  for  the  relief  they  afford 
is  so  pronounced  that  even  so  young  a  child  soon  appre- 
ciates it,  and,  instead  of  objecting  to  them,  actually  pre- 
fers to  have  them  on. 

As  to  the  possibility  of  correcting  a  convergent  squint 
by  glasses  alone,  without  resort  to  operation,  it  may  be 
said  that  this  can  be  done  always,  if  the  case  is  seen  before 
the  habit  has  become  firmlv  fixed,  that  is  to  say,  during 
the  stage  when  the  squint  is  inconstant,  is  as  yet  periodic 
in  character;  and  it  is  to  be  remembered  that  all  cases  of 
non-paralytic  squint  pass  through  such  a  stage,  unless, 
indeed,  as  sometimes  happens,  the  fault  continues  in- 


ANOMALIES    OF    REFRACTION. 


403 


definitely  to  be  periodic.  As  it  falls  to  the  lot  of  the  gen- 
eral practitioner  much  oftener  than  to  the  specialist  to 
see  these  cases  during  the  formative  stage  of  the  squint, 
the  responsibility  which  devolves  upon  him  under  the 
circumstances,  and  the  great  value  of  the  advice  which 
he  is  in  a  position  to  give,  can  not  be  too  strongly  em- 
phasized. 

Before  dismissing  the  subject  of  the  treatment  of 
hypermetropia  it  remains  only  to  observe  that,  more 
often  than  not,  hypermetropia  is  complicated  by  the 
coexistence  of  astigmatism,  and  that  in  view  of  this  and 
of  the  fact,  to  which  reference  has  already  been  made, 
that  a  clear  comprehension  of  the  muscular  anomalies 
of  the  eyes  and  of  the  influence  which  glasses  exert  upon 
them  is  essential  to  the  proper  correction  of  this  refrac- 
tive fault,  it  is  evident  that  the  treatment  of  hyperme- 
tropia is  a  matter  to  be  undertaken  only  by  the  physician 
who  has  had  especial  training  and  experience. 

Myopia  (Short-sightedness,  Near-sightedness). 
— ^This  defect  is  much  less  common  than  hypermetropia, 
from  which  it  differs  in  several  essential  respects.  In 
the  first  place,  unlike  hypermetropia,  it  is  nearly  always 
an  acquired,  seldom  a  congenital,  fault.  In  the  next 
place,  it  is  a  fault  which  is  commonly  progressive;  and, 
in  the  third  place,  it  is  usually  accompanied  by,  indeed 
is  dependent  upon,  a  pathological  condition  of  the  eye. 
As  is  hypermetropia,  inheritance  often  plays  in  myopia 
an  important  role;  but  it  is  not  the  defect  itself  that  is 
transmitted  from  one  generation  to  another,  but  rather 
a  predisposition  to  its  development. 

The  essential  fault  in  myopia  is  that  rays  of  light  en- 
tering the  eye  from  distant  objects  are  brought  to  a  focus 
not  upon  the  retina,  as  they  should  be,  but  in  front  of  it. 
This  results  either  from  the  antero-posterior  axis  of  the 


404  PREVALENT    DISEASES    OF    THE     EYE. 

eye  being  abnormally  long  or  from  an  excess  of  refractive 
power  in  the  lens  system  of  the  eye.  The  first-mentioned 
type  is  known  as  axial  myopia  (Fig.  150);  the  second, 
as  curvature  myopia.  A xial  myopia  is  the  more  common 
type  and  is  very  generally  due  to  a  yielding  of  the  eyeball 
at  its  posterior  pole,  to  the  development,  as  it  is  called, 
of  a  posterior  staphyloma.  The  sclerotic  coat  in  the 
region  of  the  macula  and  optic  nerve  entrance  is  incap- 
able of  resisting  the  intraocular  pressure  and,  being 
unsupported  here,  as  it  is  laterally,  by  the  recti  muscles, 
becomes  distended  and  thinned.  The  choroid  and 
retina  also  participate  in  the  staphylomatous  process,  and 
in  myopia  of  high  grade  usually  exhibit,  ophthalmo- 


Fig.   150. — Diagram  of  axial  myopia. 

scopically,  marked  signs  of  inflammation  and  degenera- 
tion. (See  Fig.  132.)  It  is  this  insufficiency  of  the 
sclera,  this  disposition  to  the  development  of  posterior 
staphyloma,  that  is  inherited,  and  it  is  this  that  accounts 
for  the  family  tendency  to  myopia  often  observed. 

Much  less  frequently  axial  myopia  is  the  result  of  a 
gradual  enlargement  of  the  eyeball,  of  a  general  yielding 
of  the  sclera  and  cornea,  such  as  occurs  in  the  glaucoma 
of  youth. 

In  curvature  myopia,  which,  like  axial  myopia,  is  com- 
monly an  acquired  condition,  the  cornea  is  usually  the 
seat  of  the  fault.  As  a  result  of  inflammation  or  injury 
or  in  consequence  of  some  inherent  insufficiency  the 


ANOMALIES    OF    REFRACTION. 


405 


cornea  becomes  abnormally  convex.  In  the  condition 
known  as  conical  cornea  (see  Fig.  102)  we  have  one  of 
the  most  striking  examples  of  curvature  myopia,  which 
is  often  excessive  in  amount.  Another  type  of  curvature 
myopia  is  produced  by  an  increase  in  the  convexity  of 
the  lens,  such  as  is  frequently  observed  in  the  incipient 
stage  of  cataract,  or  by  the  lens,  from  any  cause,  assum- 
ing a  position  farther  from  the  retina  than  it  normally 
occupies. 

Axial  myopia^  being  the  type  of  near-sightedness 
usually  encountered,  calls  for  fuller  consideration. 

While  the  inherited  disposition  to  the  development  of 
posterior  staphyloma  unquestionably  plays  an  impor- 
tant role  in  the  causation  of  axial  myopia,  and  in  my 
opinion  deserves  greater  consideration  than  is  usually 
accorded  it  by  recent  authors,  there  are  other  etiological 
factors  which  are  hardly  less  significant.  Among  the 
most  important  of  these,  unquestionably,  are  uncor- 
rected astigmatism  and  unrecognized  anomalies  of  the 
ocular  muscles. 

In  their  descriptions  of  the  causes  of  myopia  the  use  of 
the  eyes  in  near  vision — as  in  reading,  writing,  sewing 
and  the  like — is  usually  given  more  prominence  by 
writers,  it  seems  to  me,  than  it  deserves;  for  if  this,  of 
itself,  were  sufficient  to  produce  near-sightedness,  the 
fault  would  be  far  more  common  than  it  is.  The  nor- 
mal eye,  it  is  safe  to  say,  is  seldom  harmed  by,  is  rarely 
incapable  of  doing  without  injury,  the  work  of  this 
character  which  is  demanded  of  it.  The  eyes  that  really 
suffer — unless  indeed  the  work  required  of  them  is 
beyond  reason,  and  is  rendered  exceptionally  trying  by 
the  unfavorable  conditions  as  to  light,  position,  un- 
hygienic surroundings,  etc.,  under  which  it  must  be  per- 
formed— are  the  ones  that  start  with  some  inherent  de- 


406  PREVALENT    DISEASES    OF    THE    EYE. 

feet;  the  ones  that  are  astigmatic  or  anisometropic,  or 
in  which  there  is  a  faulty  muscle-balance,  or,  finally,  in 
which  there  exists  an  inherited  predisposition  to  myopia. 
Unquestionably,  myopia  is  much  less  apt  to  develop  in 
such  eyes  if  they  are  called  upon  to  do  but  little  near 
work,  and  to  this  extent  the  use  of  the  eyes  in  near  vision 
deserves  to  be  regarded  as  a  factor  in  the  causation  of 
near-sightedness,  but  not  as  a  factor  of  prime  im- 
portance. 

The  causative  relation  between  the  astigmatism  or 
the  muscle  fault  and  the  myopia  is  easily  traced.  The 
strain  induced  by  these  anomalies  leads  to  congestion  of 
the  inner  tunics  of  the  eye  and  in  time  to  a  low  grade  of 
choroido-retinitis,  and  this,  in  turn,  to  a  disturbance  in 
the  nutrition  of  the  sclera  and  to  the  development  of 
posterior  staphyloma.  In  no  other  country  are  the  re- 
fractive and  muscular  faults  of  the  eyes  so  diligently 
searched  for,  and  so  carefully  corrected,  as  in  the  United 
States,  and  the  outcome  of  this,  as  Dr.  Risley,  of  Phila- 
delphia, has  pointed  out,  is  that  myopia  of  high  grade  is 
by  no  means  as  common  among  us  at  the  present  day  as 
it  was  thirty  or  forty  years  ago.  On  the  other  hand,  its 
prevalence  has  rather  increased  than  diminished  during 
this  period  in  Germany,  where  there  is  a  disposition  to 
deride,  and  to  regard  as  "finicky,"  the  tendency  of  the 
American  ophthalmologists  to  prescribe  glasses  for  the 
lower  grades  of  these  defects. 

It  is  not  improbable  that,  as  a  result  of  inheritance, 
there  exists  among  the  Germans  an  exceptional  pre- 
disposition to  myopia,  which  doubtless,  in  no  small 
measure,  explains  the  wide  prevalence  of  this  fault 
among  them;  but  I  venture  the  prediction  that  the}'  will 
meet  with  but  little  success  in  overcoming  this  predis- 
position until  they  have  learned  to  emulate,  rather  than 


ANOMALIES    OF    REFRACTION.  407 

deride,  the  example  which  has  been  set  them  by  the 
ophthahnologists  on  this  side  of  the  water. 

It  is  during  the  early  years  of  life,  especially  before  the 
age  of  twenty-five,  that  the  disposition  of  myopia  to  in- 
crease is  chiefly  observed.  After  that  age,  if  the  defect 
is  not  excessive,  it  is  apt  to  become  stationary.  It  is  of 
the  greatest  importance,  therefore,  that  during  these 
early  years  every  effort  should  be  made  to  overcome  this 
tendency  to  progression;  for  while  a  moderate  degree  of 
myopia  is  only  an  inconvenience,  a  high  degree  is  a  mat- 
ter of  serious  moment,  which  may  even  eventuate  in  loss 
of  sight.  Choroido-retinitis,  involving  especially  the 
macular  region,  is  a  common  accompaniment  of  high 
myopia,  and  among  the  complications  to  be  feared  are 
intraocular  hemorrhage,  detachment  of  the  retina,  and 
the  development  of  cataract.  Very  near-sighted  eyes 
also  are  prone  to  suffer  serious  consequences  from 
slight  injuries,  which  would  do  no  harm  to  the  normal 
organ. 

The  myope  has  to  contend  with  another  difficulty 
comparable  to,  but  exactly  the  opposite  of,  that  which 
besets  the  hypermetrope.  The  latter,  as  has  been  ex- 
plained, with  his  fault  uncorrected,  must  always  put 
forth  an  effort  of  accommodation  in  excess  of  that  of 
convergence.  The  myope,  on  the  other  hand,  with  his 
fault  uncorrected,  must  converge  more  strongly  than  he 
accommodates — must  call  upon  the  internal  recti  muscles 
to  work  in  excess  of  the  ciliary  muscles.  Indeed,  if  his 
near-sightedness  is  of  considerable  degree,  because  of 
the  proximity  of  his  far  point,  he  must  converge  more 
strongly  even  than  the  emmetrope,  and  at  the  same  time 
must  do  his  best  to  suppress  entirely  all  accommodative 
effort.  To  the  myope  this  derangement  of  the  normal 
relation  between  accommodation  and  convergence  is  as 


408  PREVALENT    DISEASES    OF    THE     EYE. 

trying  as  the  derangement  of  an  opposite  character  is  to 
the  hvpermetrope,  and  when  it  becomes  intolerable  he, 
too,  abandons  the  effort  to  maintain  binocular  fixation, 
and  seeks  to  restore  the  parallelism  between  these  two 
functions  bv  permitting  one  eye  to  squint  outiiard,  just 
as  the  hvpermetrope  accomplishes  the  same  result  by 
allowing  one  eye  to  squint  inward.  If  he  does  not  find 
relief  in  this  manner  he  is  apt  to  suffer,  in  much  the 
same  way  that  the  hypermetrope  does,  with  asthenopia, 
headaches,  etc.,  while,  of  greater  moment  still,  the 
growth  of  the  myopia  is  promoted  bv  the  continual 
strain. 

While  this  disturbance  of  the  normal  relation  be- 
tween accommodation  and  convergence  is  doubtless  the 
chief  cause  of  the  occurrence  of  divergent  squint  in  high 
myopia,  there  are  other  factors  that  favor  its  develop- 
ment, especially  the  considerably  greater  length  of  the 
eyeball,  which,  for  mechanical  reasons,  renders  the 
converging  of  the  eyes  in  near  vision  more  difficult.  It 
is  also  one  of  the  chief  causes  of  the  asthenopia  fre- 
quently observed  in  myopia  of  moderate  degree,  and  it 
is  in  considerable  measure  through  its  elimination  that 
the  growth  of  near-sightedness  is  so  favorably  influenced 
by  properly  adjusted  glasses.  To  rid  themselves  of  the 
discomfort  to  which  it  gives  rise,  many  myopes,  whose 
fault  has  not  been  corrected  by  glasses,  acquire  the 
habit  of  reading  with  one  eye,  closing  the  other  or  cover- 
ing it  with  the  hand. 

In  some  instances  mvopia  is  a  result  of  acute  systemic 
disease,  especially  of  the  exanthematous  fevers.  A 
softening  of  the  sclera,  a  diminution  of  its  resisting 
power,  occurs,  and  this  leads  to  the  development  of 
posterior  staphyloma.  Without  having  sufficient  war- 
rant for  the  belief,  it  has  seemed  to  me  probable  that 


ANOMALIES    OF    REFRACTION.  4O9 

the  extreme  degrees  of  myopia  not  infrequently  encoun- 
tered among  the  negroes  in  the  South  commonly  origi- 
nate in  this  way. 

The  most  characteristic  symptom  of  myopia  is  in- 
distinctness of  distant  vision.  There  is  a  prevalent  be- 
lief that  the  existence  of  myopia  incapacitates  one  from 
reading  at  the  usual  distance;  but  this,  of  course,  is  erro- 
neous, since  it  is  only  of  the  higher  grades  of  the  defect 
that  it  is  true.  Besides  poor  distant  vision,  the  myope 
i  is  apt  to  complain  of  muscae  volitantes  and,  as  has  been 
said,  of  asthenopia.  To  enable  him  to  see  distant  ob- 
jects better,  he  frequently  acquires  the  habit  of  keeping 
the  eyes  half  closed,  of  nipping  the  lids,  and  it  is  from 
this  habit  that  the  name  "myopia"  is  derived.  How- 
ever, none  of  these  symptoms  is  pathognomonic,  for  they 
all  are  met  with  in  other  refractive  errors,  notably  in 
astigmatism  of  marked  degree. 

The  ophthalmoscope  affords  a  certain  and  the  read- 
iest means  of  making  a  positive  diagnosis.  It  enables 
one  also  to  determine  with  approximate  accuracy  the 
amount  of  the  defect,  and,  besides,  throws  much  light 
upon  the  probable  prognosis;  for,  even  when  the  myopia 
is  of  considerable  degree,  if  there  are  no  gross  patholog- 
ical changes  in  the  fundus  of  the  eye,  the  outlook  for  the 
future  is  not  unpromising.  Other  things  being  equal,  it 
may  be  said  that  the  earlier  in  life  myopia  develops, 
and  the  higher  the  grade  already  reached  in  childhood, 
the  more  unfavorable  is  the  prognosis,  and  for  the 
reason  already  referred  to — that  it  is  in  adolescence  that 
the  defect  is  chiefly  progressive. 

Treatment. — If  special  training,  experience,  and  pains- 
taking effort  are  required  for  the  proper  treatment  of 
hypermetropia,  they  are  the  more  urgently  demanded  in 
the  treatment  of  myopia;    for  the  defect  is  not  only,  in 


410  PREVALENT    DISEASES    OF    THE     EYE. 

itself,  more  difficult  to  measure  and  correct,  and  as  often 
complicated  bv  the  presence  of  astigmatism  and  faulty 
muscle-balance,  but  its  existence  implies  an  unsound 
condition  of  the  eve,  so  that  not  only  the  comfort  of  the 
individual,  but,  in  manv  instances,  the  preservation  of 
sight  is  at  stake.  The  question  whether  the  defect  shall 
increase  to  the  danger-point,  or  shall  be  arrested  before 
the  deeper  structures  of  the  eye  have  suffered  irreparable 
damage,  hinges,  in  large  measure,  upon  the  skill  exer- 
cised in  its  correction  by  glasses  (Fig.   151). 

If  the  astigmatism    so   often    found    in    association 
with    myopia    is    ignored    or    inaccurately    corrected, 


Fig.  151. — Manner  in  which  a  concave  lens  causes  parallel  rays  to  diverge 
as  from  the  far  point  of  a  myopic  eye  (de  Schweinitz). 

or  if  the  muscle-balance  in  far  and  in  near  vision 
and  the  accommodative  power  of  the  eyes  are  not  taken 
into  account,  the  glasses  prescribed  are  more  apt 
to  be  productive  of  harm  than  of  good.  On  the 
other  hand,  if  in  their  selection  regard  is  had  for  each 
of  these  points  thev  can  hardly  fail  to  exert  a  dis- 
tinctlv  beneficial  mfiuence.  It  is  not  too  much  to  e.x- 
pect  that  thev  will  relieve  the  asthenopic  symptoms,  and 
enable  the  eyes  to  be  used  in  near  vision,  at  least  in  mod- 
eration, without  the  risk  of  increasing  the  mvopia.  It  is 
true  that,  exceptionalh-,  there  are  instances — as  when 
near-sightedness  of  high  grade  is  already    present    in 


ANOMALIES    OF    REFRACTION.  4II 

childhood — in  which,  even  with  the  help  of  glasses, 
the  near  use  of  the  eyes  is  not  to  be  permitted;  but  such 
cases  are  comparatively  rare,  and,  as  a  rule,  if  the  glasses 
afford  the  help  which  they  should,  we  shall  run  but  little 
risk  in  permitting  the  eyes  to  be  used  in  near  work,  pro- 
vided we  see  to  it  that  they  are  not  taxed  immoderately, 
that  the  printed  page  or  other  object  to  be  regarded  is 
well  lighted  and  kept  at  the  proper  distance,  and  that  a 
stooping  posture  of  the  head  is  avoided. 

There  is  a  wide-spread  belief  that  in  myopia  glasses 
are  needed  for  distant  vision  only,  and  that  because  fine 
print  can  be  read  without  their  assistance  they  may  be 
dispensed  with  in  near  vision.  Seldom  is  this  belief 
well  founded.  Indeed,  very  generally  it  is  far  more 
important  for  the  welfare  of  the  eyes  that  they  should 
be  worn  in  near,  than  that  they  should  be  used  in  dis- 
tant, vision.  In  distant  vision  they  are  a  convenience; 
in  near  vision  they  are  a  therapeutic  agent  of  great  value. 
If  the  myopia  is  of  moderate  degree,  is  equal  in  the  two 
eves,  is  uncomplicated  by  astigmatism,  and  if,  in  addi- 
tion, as  seldom  happens,  the  muscle-balance  at  the  read- 
ing distance  is  what  it  should  be,  glasses  for  near  vision 
may  be  dispensed  with;  but,  as  a  matter  of  fact,  such 
conditions  seldom  obtain.  It  is  often  a  difficult  matter 
to  persuade  the  myope  to  wear  reading  glasses,  and  a 
contention  is  apt  to  arise  when  this  point  is  broached; 
but  in  the  end  he  seldom  fails  to  realize  the  help  which 
they  afford.  Exceptionally,  the  contention  takes  a  dif- 
ferent form — a  willingness  is  shown  to  wear  near  glasses, 
while  objection  is  made  to  their  use  in  distant  vision. 
It  is  not  always  so  necessary  to  combat  this  view,  and 
the  point  may  be  yielded,  provided  the  eyes  are  free 
from  muscular  fault  and  are  not  decidedly  astigmatic. 

Whether  the  same  glasses  may  be  worn  in  both  far 


412  PREVALENT    DISEASES    OF    THE     EYE. 

and  near  vision  will  depend  upon  the  degree  of  the  my- 
opia, upon  the  age  and  accommodative  power  of  the 
individual,  and  upon  the  relative  strength  of  the  external 
and  internal  recti  muscles.  In  youth,  if  the  myopia 
does  not  exceed  two  or  three  diopters,  and  there  is  nor- 
mal power  of  accommodation,  it  is  usually  good  practice 
to  prescribe  glasses  which  give  satisfactory  distant 
vision,  and  permit  these  to  be  worn  for  all  purposes. 
Later  in  life,  when  the  eyes  have  lost  part  of  their  accom- 
modative power,  this  is  impracticable,  and  weaker 
glasses  must  be  provided  for  near  vision.  Again,  in 
;  myopia  of  high  grade  it  is  usually  best  not  to  correct  the 
entire  fault,  and,  under  such  circumstances,  the  same 
glasses  may  often  be  worn  in  both  far  and  near  vision. 

Whenever  a  considerable  amount  of  myopia  is  present 
in  childhood  the  eyes  should  be  examined  from  time  to 
time,  in  order  to  learn  whether  the  fault  is  increasing, 
and  if  this  is  found  to  be  the  case  greater  moderation  in 
the  use  of  the  eyes  in  near  vision  should  be  insisted  upon. 

Apart  from  the  systematic  wearing  of  carefully 
adjusted  glasses,  and  the  exercise  of  such  precautions  as 
have  been  set  forth  in  the  near  use  of  the  eyes,  the 
progress  of  myopia  is  favorably  influenced  by  meas- 
ures which  improve  the  general  health.  In  youth,  espe- 
cially, reading  for  pleasure  should  be  discountenanced, 
and  participation  in  outdoor  occupations  and  amuse- 
ments should  be  encouraged.  Rough  sports,  however, 
such  as  football,  boxing,  and  the  like,  should  be  avoided. 
The  digestive  apparatus  should  be  kept  in  good  con- 
dition, and  constipation  of  the  bowels  should  be 
avoided.  When  the  eyes  are  irritable  and  the  near- 
sightedness inclined  to  increase,  I  have  found  decided 
benefit  result  from  the  long-continued  use  of  the  opium 
and  boracic  acid  lotion  (ext.  opii,  gr.  x;    acid,  boracic. 


ANOMALIES    OF    REFRACTION. 


413 


gr.  xl;  aq.  destil.,  5iv)  which  I  have  had  occasion  to 
commend  so  often.  It  should  be  used  systematically 
during  the  sleeping  hours,  not  too  heavy  pads  of  gauze 
or  soft  linen,  wet  with  the  lotion,  being  laid  over  the 
eyes,  and  kept  in  place  by  a  light  bandage. 

Operative  procedures  are  seldom  called  for,  though, 
exceptionally,  when  there  is  pronounced  insufficiency 
of  the  internal  recti  muscles  a  guarded  tenotomy 
of  one  or  both  of  the  opponent  muscles  may  be  indi- 
cated. Removal  of  the  crystalline  lens  for  the  correc- 
tion of  myopia  of  very  high  grade,  a  practice  which  of 
late  years  has  come  into  vogue,  is  a  procedure  of  doubt- 
ful advantage,  and  one  attended  by  considerable  risk, 
and  the  cases  in  which  it  is  justified  are,  in  my  judg- 
ment, extremely  rare. 

Astigmatism. — Next  to  hypermetropia  astigma- 
tism is  the  commonest  of  the  refractive  anomalies.  An 
astigmatic  eye,  as  the  name  indicates  (dazlj-fia,  "with- 
out a  point"),  is  one  that  is  incapable  of  bringing  the 
rays  of  light  which  enter  it  to  a  focal  point.  There  are 
two  types  of  astigmatism — regular  astigmatism,  usually 
of  congenital  origin,  and  irregular  astigmatism,  which  is 
frequently  an  acquired  fault.  Irregular  astigmatism  has 
been  described  already  in  treating  of  "  Opacities  of  the 
Cornea  "  and  does  not  call  for  further  consideration. 

Regular  astigmatism,  often  transmitted  from  one  gen- 
eration to  another,  is  commonly  due  to  asymmetry  in 
the  curvature  of  the  cornea,  to  the  different  meridians 
of  the  cornea  varying  in  their  convexity;  less  frequently, 
to  asymmetry  in  the  curvature  of  the  crystalline  lens, 
or  to  the  lens  occupying  an  oblique  position  with  refer- 
ence to  the  visual  axis.  The  result  of  each  of  these 
faults  is  that  the  rays  of  light  passing  through  the  differ- 
ent meridians  of  the  dioptric  media  of  the  eye  are  un- 


414  PREVALENT    DISEASES    OF    THE    EYE. 

equally  refracted,  those  which  pass  through  the  most 
convex  meridian,  or  through  the  meridian  to  which  the 
obliquity  of  the  lens  corresponds,  being  most  quickly 
focused,  those  through  the  less  convex  meridians  less 
quickly,  and  those  through  the  least  convex  meridian, 
or  through  the  meridian  corresponding  to  the  axis  about 
which  the  lens  is  rotated,  least  quickly.  The  outcome 
of  this  is  an  imperfect,  a  blurred,  retinal  image,  w^hich 
is  very  annoying,  and  which  the  eye,  at  the  expense  of 
much  effort,  endeavors  to  make  more  distinct.  The 
amount  of  blurring  depends  upon  the  measure  of  success 
which  attends  this  effort,  as  well  as  upon  the  degree  of 
the  astigmatism. 

In  some  eves  a  large  part  of  the  static  astig- 
matism is  corrected,  is  rendered  "latent,"  through 
the  action  of  the  ciliary  muscle,  which,  contracting 
asymmetrically,  produces  a  compensatory  lenticular 
astigmatism  or,  perhaps,  a  tilt  of  the  lens,  which  serves 
the  same  purpose.  It  is  the  ever-present  strain  involved 
in  this  effort  that  is  the  chief  cause  of  the  asthenopia, 
the  headaches,  etc.,  so  commonly  associated  with  astig- 
matism. A  fact  confirmatory  of  this  is  that  when  the 
astigmatism  is  of  very  high  grade  there  is  usually  little 
complaint  of  asthenopia,  only  of  imperfect  vision,  be- 
cause, under  such  circumstances,  the  eye  soon  learns 
that  by  no  effort  which  it  is  capable  of  making  can  clear 
vision  be  secured,  and  so  abandons  the  task  and  accepts 
the  inevitable. 

Many  astigmatic  persons  also  learn  to  improve  their 
vision,  as  myopes  do,  by  nipping  the  lids,  whereby  they 
not  only  secure  the  advantage  of  a  narrow,  slit-shaped 
pupil,  but,  through  the  pressure  exerted  by  the  lids, 
actually  alter  to  their  advantage  the  curvature  of  the 
cornea.     In  order  to  obtain  a  larger  retinal  image  they 


ANOMALIES    OF    REFRACTION.  415 

also  frequently  hold  the  printed  page  abnormally  close 
to  the  eyes.  For  these  reasons,  and  because  their  dis- 
tant vision  is  manifestly  indistinct,  they  are  often  sup- 
posed to  be  myopic.  Unlike  that  of  the  myope,  how- 
ever, their  vision,  if  the  defect  is  considerable  in  degree, 
is  imperfect  at  all  distances.  They  are  more  sure,  too, 
to  be  asthenopic,  and,  as  has  been  pointed  out,  they  are 
liable  to  many  grave  lesions  of  the  eye  in  consequence 
of  the  ever-present  strain  to  which  their  accommodative 
apparatus  is  subjected. 

The  simplest  form  of  astigmatism  is  that  in  w^hich  the 
eye  is  emmetropic  in  one  meridian  and  hyperme- 
tropic or  myopic  in  the  opposite  meridian.  This 
type  of  the  defect,  simple  astigmatism,  as  it  is  called, 
is,  however,  the  exception,  and  it  is  usually  with  com- 
pound astigmatism  that  we  have  to  deal,  that  is,  with 
astigmatism  in  which  there  is  hypermetropia  or  myopia, 
as  the  case  may  be,  in  one  meridian  and  a  greater 
amount  of  the  same  defect  in  the  opposite  meridian. 
More  rarely  ynixed  astigmatism  is  encountered^there 
is  hypermetropia  in  one  meridian  and  in  the  opposite 
meridian  myopia. 

In  corneal  astigmatism  the  meridian  of  shortest  focus 
is  apt  to  be  approximately  vertical,  the  meridian  of 
longest  focus  approximately  horizontal.  In  lenticular 
astigmatism,  on  the  other  hand,  it  is  usual  to  find  the  con- 
ditions reversed.  The  first  type,  being  the  more  com- 
mon, is  known  as  astigmatism  with,  or  according  to,  the 
rule;  the  last,  as  astigmatism  against  the  rule.  A  low 
grade  of  astigmatism  "with  the  rule,"  a  quarter  of  a 
diopter,  for  example,  usually  gives  rise  to  little  or  no 
inconvenience,  indeed,  is  so  common  as  hardlv  to  be  re- 
garded as  an  abnormality.  On  the  contrary,  astigma- 
tism "against  the  rule,"  generally  located,  as  has  been 


4l6  PREVALENT    DISEASES    OF    THE    EYE. 

said,  in  the  lens,  deserves  to  be  regarded  as  a  wider  de- 
parture from  the  normal,  and,  though  it  be  ever  so 
slight  in  degree,  is  apt  to  cause  trouble.  Even  the 
lowest  grades  of  astigmatism  against  the  rule,  therefore, 
should  be  corrected — the  more  so  because  the  discrep- 
ancy between  the  manifest  and  the  total  defect  is  apt  to 
be  greater  than  is  the  case  in  astigmatism  with  the  rule. 

The  fact,  of  frequent  observation,  that  astigmatic 
glasses  after  having  been  worn  for  some  months  have  to 
be  increased  in  strength,  finds  its  explanation  in  this 
latency  of  a  part  of  the  error.  Latent  hypermetropia 
usually  can  be  made  evident  by  a  few  instillations  of  a 
cycloplegic;  but  this  is  not  true  of  latent  astigmatism. 
Only  as  a  result  of  the  correction  of  the  manifest  defect 
does  the  induced,  the  compensatory,  lenticular  astig- 
matism slowly  disappear,  and  the  static  error  become 
fully  manifest.  Thus  it  happens  that  an  eye  which  is 
made  comfortable  for  half  a  year  or  more  by  a  cylindrical 
glass  of  a  certain  strength  may  eventually  call  for  one 
twice  as  strong.  In  exceptional  instances,  especially 
in  progressive  myopia,  there  may  be  an  actual  increase  of 
astigmatism;  but  commonly  it  remains  unchanged, 
and  there  is  only  an  apparent  increase  due  to  the  defect 
becoming  more  and  more  manifest. 

There  is  a  popular  impression  that  an  astigmatic 
glass  once  right  is  always  right;  but,  like  many 
such  impressions,  this  one  is  without  warrant. 
Indeed,  not  only  may  an  increase  in  the  strength 
of  the  glass  be  called  for,  but  also  a  change  in 
its  position;  for  the  astigmatism  may  undergo  what  is 
known  as  orientation — a  change  may  occur  in  the  direc- 
tion of  the  principal  meridians,*  doubtless  another  re- 

*  The  meridians  of  greatest  and  of  least  convexity  are  called  the 
"  principal  meridians,"  and  are  at  right  angles  to  each  other. 


ANOMALIES    OF    REFRACTION.  4I7 

suit  of  the  effort  which  the  eye  puts  forth  to  correct  its 
own  defect. 

Although  regular  astigmatism  is  usually  a  congenital 
fault  and  frequently,  as  has  been  said,  an  inherited  one, 
it  may  also  be  acquired.  Acquired  astigmatism  is  often 
of  traumatic  origin.  Any  wound  of  the  eye  which  pro- 
duces a  permanent  change  in  the  curvature  of  the  cornea 
may  give  rise  to  it.  A  familiar  example  of  this  is  the 
astigmatism  against  the  rule  which  very  generally  fol- 
lows the  operation  of  cataract  extraction.  Severe  in- 
flammation of  the  cornea  may  also  produce  it,  more 
especially  a  perforating  corneal  ulcer.  It  is  more  incon- 
stant than  congenital  astigmatism,  being  liable  to  vary 
in  degree  as  the  asymmetry  of  the  cornea  increases  or 
diminishes,  and  because  of  this  tendency  a  readjustment 
of  the  glasses  prescribed  for  its  correction  is  more  often 
necessary. 

Because  the  common  belief  is  to  the  contrary,  it  is  well 
to  emphasize  the  fact  that  the  existence  of  a  degree  of 
astigmatism  capable  of  giving  rise  to  pronounced 
asthenopic  symptoms  is  not  incompatible  with  normal 
acuteness  of  vision.  Especially  is  this  true,  in  my  ex- 
perience, of  astigmatism  against  the  rule,  of  which  the 
eye  seems  more  intolerant,  and  with  which,  so  far  as 
sharpness  of  vision  is  concerned,  it  seems  to  cope  more 
successfully.  Often  have  I  met  with  cases  of  this  de- 
fect in  which,  without  glasses,  vision  was  fully  up  to  the 
normal  standard,  and  yet  in  which  the  prescribing  of 
weak  cylinders  has  afforded  immediate  relief  from  head- 
aches, asthenopia,  etc. 

The  detection  of  the  lower  grades  of  astigmatism  is  a 

matter  which  often  taxes  the  skill  of  the  specialist;    but 

when  the  error  is  marked  in  degree  it  is  not  difficult  to 

prove  its  existence.     The  easiest  way  to  do  this  is  by 

27 


4l8  PREVALENT    DISEASES    OF    THE    EYE. 

means  of  a  stenopaic  disc,  or,  if  this  is  not  available,  by 
means  of  an  improvised  stenopaic  apparatus  which  any 
one  can  make  by  cutting  a  narrow  sHt  in  a  visiting-card. 
When  such  a  contrivance  is  held  in  front  of,  and  close  to, 
an  eye  the  vision  of  which  is  defective  from  any  refrac- 
tive error,  an  appreciable  improvement  in  vision,  espe- 
cially in  distant  vision,  will  result.  If  the  defective 
vision  is  due  to  a  symmetrical  error,  for  example,  to  my- 
opia, the  improvement  will  be  the  same  in  whatever 
direction  the  slit  is  turned.  If,  however,  it  is  due  to 
astigmatism,  vision  will  be  much  sharper  when  the  slit 
is  held  in  a  certain  easily  found  position,  and  much  less 
sharp  when  it  is  held  in  the  opposite  direction.  The 
test  is  a  rough  one;  but,  if  the  difference  in  vision  is 
considerable  in  the  two  positions,  it  is  conclusive,  and 
warrants  a  positive  diagnosis  of  astigmatism.  It  also 
indicates  the  direction  of  the  principal  meridians,  since 
the  greatest  improvement  in  sight  is  obtained  when  the 
slit  is  held  at  a  right  angle  to  the  faulty  meridian,  or,  if 
both  are  at  fault,  to  the  one  which  is  most  so.  How- 
ever, as  this  test  is  conclusive  only  when  the  astigmatism 
is  considerable  in  degree,  it  should  be  borne  in  mind 
that  a  negative  result  does  not  exclude  the  possible  ex- 
istence of  a  significant  amount  of  the  defect. 

Since  astigmatism  is  so  prevalent  an  error,  and  is  so 
often  a  chief  factor  in  the  causation  not  only  of  a  host 
of  ocular  maladies  but  of  many  obscure  disturbances 
of  the  nervous  system,  such  as  headache,  neurasthenia, 
nausea,  nervous  dyspepsia,  vertigo,  insomnia,  somno- 
lency, incapacity  for  mental  concentration,  chorea,  etc., 
its  significance,  its  etiologic  importance,  can  not  be  too 
strongly  impressed  upon  the  general  practitioner. 
** Remember  the  eyes"  is  a  dictum  which,  if  taken  to 
heart,  will  often  stand  him  in  good  stead,  and  enable 


ANOMALIES    OF    REFRACTION.  •    4I9 

him  to  solve  many  a  diagnostic  riddle  which  otherwise 
might  prove  insolvable. 

Treatment. — There  is  but  one  way  to  treat  astigma- 
tism, and  that  is,  with  painstaking  care,  to  correct  it  by 
means  of  glasses;  for,  being  simply  a  defect  in  the  con- 
formation of  the  eye  and  not  a  pathological  condition, 
there  are  no  means  by  which  it  can  be  eliminated  or  even 
lessened  in  amount.  Theoretically,  the  gl-asses  pre- 
scribed for  its  correction  should  be  worn  constantly; 
but,  practically,  this  is  not  always  necessary,  for  when 
the  defect  is  of  low  grade,  and  is  approximately  with 
the  rule,  complete  relief  is  not  infrequently  obtained 
by  their  systematic  use  m  near  vision  only.  In  astig- 
matism against  the  rule,  even  if  the  error  be  slight  in 
degree,  it  seldom  happens  that  relief  is  secured  unless 
the  glasses  are  worn  constantly.  This  is  usually  the 
case  also  when  there  is  a  considerable  difference  in  the 
amount  of  the  astigmatism  in  the  two  eyes,  or  when  it  is 
with  the  rule  in  one  eye  and  against  the  rule  in  the  other. 
As  oftener  than  not  other  refractive  faults  are  found 
associated  with  astigmatism,  the  question  whether  the 
glasses  shall  be  worn  only  in  near  vision  or  constantly 
may  depend  upon  the  nature  of  the  associated  error. 

It  is  by  means  of  cylindrical  lenses  that  we  are  enabled 
to  correct  astigmatism.  If  the  astigmatism  is  "simple"  a 
piano-cylindrical  lens  suffices  for  its  correction — a  plano- 
concave cylinder  (Fig.  152)  if  the  astigmatism  is  myopic, 
a  plano-convex  cylinder  (Fig.  153)  if  it  is  hypermetropic. 
If  the  astigmatism  is  "compound"  or  "mixed,"  a 
sphero-cylindrical  lens  is  usually  necessary,  that  is,  a  lens 
one  surface  of  which  is  spherical — concaveor  convex,  as 
the  case  may  be — and  the  other  cylindrical.  In  the  direc- 
tion of  its  axis  a  piano-cylinder  has  only  the  refractive 
value  of  a  plate  of  glass  with  parallel  surfaces,  while  in 


420 


PREVALENT    DISEASES    OF    THE    EYE. 


the  direction  perpendicular  to  its  axis  its  refractive  power 
is  greatest.  Hence  the  effect  of  a  cyhndrical  lens  upon 
vision  depends  upon  the  position  in  which  the  axis  is 
placed.  It  is  necessary,  therefore,  in  prescribing  glasses 
for  the  correction  of  astigmatism  to  determine  with  ac- 
curacy not  onlv  the  required  strength  of  the  cylinder, 
but  also  the  exact  position  in  which  it  is  to  be  worn. 
The  question  whether  a  piano-cylinder  or  a  sphero- 
cylinder  is  required  has  also  to  be  determined,  and,  if 
the  latter  is  called  for,  what  shall  be  the  strength  of  the 
spherical  surface.     And  here,  again,  it  is  of  the  utmost 


Fig.  i: 


-PlaiK. 


jncave  cylinder.         Fig.  153. — Plano-convex  cylinder. 


importance  that  the  muscle-balance  of  the  eyes  should 
be  taken  into  account. 

The  correction  of  astigmatism  by  means  of  cylindrical 
lenses  has  a  twofold  effect — vision  is  greatly  improved, 
in  most  instances  brought  up  to  the  normal  standard, 
and,  even  more  important  than  this,  the  previously  ex- 
isting accommodative  strain  is  relieved.  The  latter 
effect  may  well  be  called  the  more  important,  since  it  is 
through  this  that  relief  is  obtained  from  the  manv  ill 
consequences,  local  and  remote,  to  which  uncorrected 
astigmatism  usuallv  gives  rise. 

It  is  well  to  bear  in  niiiid  that  the  relief  which  cylin- 
drical lenses  afford  is  not  appreciated,  in  many  instances, 
until  they  have  been  worn  for  a  time — long  enough  for 


ANOMALIES    OF    REFRACTION.  42I 

the  eyes  to  learn  to  adjust  themselves  to  the  new  condi-\ 
tions,  and  to  accept  the  help  which  they  give.  Indeed, 
when  they  are  first  put  on  a  transient  aggravation  of  the 
asthenopic  symptoms  is  experienced  not  infrequently. 
In  children  this  seldom  happens,  but  in  persons  more 
advanced  in  age  it  is  often  pronounced.  It  is  well, 
therefore,  that  the  patient  should  be  warned  before- 
hand what  to  expect,  otherwise  the  glasses  may  be 
petulantly  thrown  aside  under  the  impression  that 
they  "do  not  suit,"  and  much  undeserved  opprobrium 
heaped  upon  the  one  who  has  prescribed  them. 

How  long  the  glasses  first  given  will  continue  to 
afford  the  needed  relief  is  a  matter  of  much  uncer- 
tainty. Exceptionally,  especially  in  astigmatism  against 
the  rule,  a  change  may  be  called  for  within  a  few 
months,  while  in  other  instances  they  may  be  w'orn 
with  comfort  for  many  years. 

In  youth,  so  far,  at  least,  as  the  astigmatism  is  con- 
cerned, the  same  glasses  may  be  worn  for  all  purposes,  for 
near  as  well  as  for  distant  vision ;  but  after  the  presbyopic 
age  has  been  reached  a  lens  especially  adapted  for  near 
vision  becomes  necessary — one  that,  in  addition  to  cor- 
recting the  astigmatism,  will  afford  the  needed  mag- 
nifying power.  As  a  rule,  this  can  be  done  most  con- 
veniently by  means  of  a  bifocal  lens,  by  adding  to  the 
distance  glass  a  "lenticular"  of  the  required  strength. 

There  are  several  methods  by  which  the  existence  of 
astigmatism  can  be  ascertained  and  its  direction  and 
degree  determined.  The  ophthalmoscope  affords  the 
readiest  means  of  doing  this,  and  this  method  has  the 
great  advantage  that  it  does  not  necessitate  the  use  of 
a  cycloplegic;  but  even  in  the  hands  of  the  most  expert 
the  information  which  it  gives  is  only  approximately 
exact,  and  must  be  confirmed  by  other  means.     The 


422  PREVALENT    DISEASES  OF    THE     EYE. 

ophthalmometer,  which  some  hold  in  high  esteem,  is 
not  to  be  rehed  upon,  since  it  gives  only  the  astigmatism 
of  the  anterior  surface  of  the  cornea,  and  tells  us  noth- 
ing of  asymmetry  either  of  the  posterior  corneal  sur- 
face or  of  the  lens.  Skiascopy,  the  shadow  test,  or,  as 
it  is  sometimes  called,  retinoscopy,  affords  much  more 
exact  results,  and  is  the  most  trustworthy  of  the  ob- 
jective methods  of  measuring  astigmatism  as  well  as 
other  refractive  errors,  but  its  employment  necessitates 
the  use  of  a  cycloplegic. 

Of  all  the  methods  of  measuring  astigmatism  the 
most  reliable — the  court  of  last  resort,  as  it  has  been 
called — is  the  subjective  method,  the  test  with  glasses, 
test-types,  and  the  astigmatic  dial.  Even  here  contra- 
dictory results  and  inconsistencies  are  not  uncommon, 
and  it  often  happens  that  in  endeavoring  to  reach  a 
definite  conclusion  the  skill  and  patience  of  the  most 
experienced  are  sorely  tried.  The  beginner  usually 
derives  much  help  from  the  use  of  a  cycloplegic,  and 
in  the  opinion  of  many  this  is  essential  to  the  attainment 
of  accurate  results.  With  this  view,  however,  I  am 
not  in  accord;  for  my  experience  is  that,  in  many  in- 
stances, the  dilatation  of  the  pupil  attendant  upon  the  em- 
ployment of  a  cycloplegic  introduces  as  many  x  quan- 
tities as  are  eliminated  through  the  suppression  of  the 
power  of  accommodation.  The  advantage  gained  from 
the  paralysis  of  the  ciliary  muscle  is  unquestionably 
great;  but  this  is  nearlv,  if  not  quite,  offset  bv  the  dis- 
advantage of  having  to  make  the  visual  tests  with  a 
widely  dilated  pupil.  The  problem  would  be  different 
did  we  possess  a  cycloplegic  which  was  not  a  mydriatic 
— a  pupil  dilator — as  well,  or  had  Nature  been  less 
niggardly,  and  made  the  whole  of  the  cornea  and  the 
whole  of  the  cr)'stalline  lens  as  optically  perfect  as  she 


ANOMALIES    OF    REFRACTION.  423 

has  the  visual  zone  of  each ;  but  such  a  cycloplegic  has  yet 
to  be  found,  and,  as  the  ophthahnoscope  and  skiascopy 
have  shown  us.  Nature,  as  yet,  has  busied  herself  but 
little  in  perfecting  those  outlying  portions  of  the  cornea 
and  lens  which,  under  usual  conditions,  take  no  part  in 
the  formation  of  retinal  images.*  To  show  how  great 
may  be  the  lack  of  agreement  between  the  results  of 
tests  made  with  and  without  a  cycloplegic,  I  may  men- 
tion that  in  a  few  instances  I  have  found  the  total  hyper- 
metropia  to  be  less  than  the  manifest,  and  in  a  few 
others  have  seen  the  direction  of  an  astigmatism 
exactly  reversed  through  the  induction  of  mydriasis. 
Still,  I  would  not  be  understood  as  being  opposed  in 
general  to  the  use  of  a  cycloplegic  as  an  aid  in  the  de- 
termination of  refractive  errors;  for  I  recognize  the  fact 
that,  in  not  a  few  instances,  a  dilated  pupil  is  a  lesser 
evil  than  an  irritable  ciliary  muscle,  which  is  changing 
its  tension  from  moment  to  moment. 

There  is  a  popular  impression  that  after  glasses  pre- 
scribed for  the  correction  of  astigmatism  have  been 
worn  for  a  time,  and  have  given  the  needed  relief,  they 
may  be  put  aside  without  detriment.  It  is  hardly  neces- 
sary to  say  that  this  is  rarely  the  case.  In  low  grades 
of  astigmatism  with  the  rule,  especially  if  the  work  re- 
quired of  the  eyes  becomes  less  exacting,  this  some- 
times happens;  but,  as  a  general  truth,  it  may  be  said 
that  cylindrical  glasses  once  needed  are  always  needed. 
"Until  you  get  to  heaven,"  is  the  way  I  sometimes 
put  it  in   answer  to  the  frequently  propounded  ques- 

*  It  is  interesting  to  note  that  this  is  especially  true  of  the  eye  of 
the  negro.  I  am  not  aware  that  attention  has  been  called  to  this 
fact ;  but  from  my  own  observation  I  have  no  hesitation  in  stating 
it  as  a  fact.  Especially  does  one  find  frequently  in  the  eye  of  the 
negro  marked  examples  of  "symmetrical  aberration,"  as  defined  by 
Jackson. 


424  PREVALENT    DISEASES    OF    THE     EYE. 

tion,  "How  long  shall  I  have  to  wear  these  horrid 
glasses  ?" 

Anisometropia  is  the  rather  awkward  term  em- 
ployed to  designate  a  difference  between  the  refractive 
state  of  the  two  eyes.  When  of  moderate  degree  this 
condition  often  gives  rise  to  asthenopia,  because  of  the 
unequal  accommodative  effort  which  it  necessitates; 
when  pronounced,  it  tends  to  promote  the  development 
of  strabismus.  Exceptionally,  it  proves  a  blessing  in 
disguise,  one  eye  being  used  w4th  satisfaction  m  distant 
vision,  the  other  with  equal  satisfaction  in  near  vision. 
This  is  the  case  especially  when  one  eye  happens  to  be 
moderately  myopic,  the  other  nearly  emmetropic;  for 
under  such  circumstances  the  emmetropic  eve  does  good 
service  in  distant  vision,  while  the  myopia  of  the  other  eye 
serves  the  purpose  of  a  convex  lens,  and  obviates  the 
necessity  of  presbyopic  glasses.  As  a  change  in  the  re- 
fraction of  either  eye  is  liable  to  occur,  the  difference 
between  the  two  may  vary,  the  anisometropia  be- 
coming, in  the  course  of  time,  greater  or  less,  as  the  case 
may  be. 

Treatment. — As  a  rule,  it  is  practicable  and  best  to 
equalize  the  focus  of  the  eyes  by  giving  to  each  the  lens 
which  its  refractive  fault  calls  for.  In  most  instances, 
by  making  the  sight  and  the  accommodative  effort  of 
the  two  equal,  this  results  in  the  establishment  of  com- 
fortable binocular  vision.  However,  it  is  not  ahvays 
feasible  to  do  this.  In  the  first  place,  the  difference 
between  the  required  glasses  may  be  so  great  as  to  ren- 
der impracticable  fusion  of  the  retinal  images,  which 
under  such  circumstances  would  differ  considerably 
in  size.  In  the  next  place,  when  the  eyes  have  been 
long  divorced,  so  to  speak,  pronounced  muscular  faults 
are  apt  to  develop.     These  give  rise  to  no  inconvenience 


ANOMALIES    OF    ACCOMMODATION. 


425 


as  long  as  the  eyes  make  no  effort  to  work  together, 
but  are  hable  to  cause  much  annoyance  when,  through 
the  action  of  glasses,  binocular  vision  is  reestablished. 
Such  muscular  faults  frequently  disappear  as  a  result 
of  the  new  relations  established  between  the  eyes;  but 
this  is  not  always  the  case. 

The  difference  in  strength  which  it  is  practicable  to 
make  between  the  glasses  prescribed  for  the  correction 
of  anisometropia  varies  considerably  in  different  in- 
dividuals. In  some  instances  a  difference  of  4  or  5 
diopters  proves  acceptable,  while  in  others  a  difference 
appreciably  less  than  this  may  give  rise  to  annoyance. 
In  the  very  high  grade  of  anisometropia  which  exists 
when  one  eye  has  been  operated  upon  for  caratact,  and 
the  other  eye  still  retains  good  sight,  it  is  seldom  possible, 
by  any  arrangement  of  glasses,  to  secure  comfortable 
binocular  vision.  Under  such  circumstances  it  is  best, 
therefore,  to  give  a  glass  to  the  sharper-seeing  eye  only. 
If  this  happens  to  be  the  one  that  has  been  operated 
upon  for  cataract,  it  may  be  necessary,  in  order  to  es- 
tablish the  habit  of  using  this  eye,  to  "exclude"  the 
other  eye  for  a  time  by  placing  an  opaque  disc  or  a 
ground  glass  before  it. 

ANOMALIES  OF  ACCOMMODATION. 
A  sharp  distinction  is  to  be  drawn  between  the  anom- 
alies of  accommodation  and  the  anomalies  of  refraction. 
The  latter,  as  has  been  explained,  are  the  expression 
of  certain  faults  in  the  conformation  of  the  eye;  the 
former  have  to  do  with  the  capacity  of  the  eye  to  alter 
its  focus,  to  adjust  itself  to  the  sharp-seeing  of  objects 
at  varying  distances.  To  a  comprehension  of  the  anom- 
alies of  accommodation  a  clear  conception  of  the  normal 
accommodation  of  the  eye  is  essential. 


426 


PREVALENT    DISEASES    OF    THE    EYE. 


According  to  the  commonly  accepted  theory  of  the 
accommodation  of  the  eye,  propounded  by  Helmholtz, 
the  crystalHne  lens,  when  unrestrained,  has  an  inherent 
tendency  to  become  more  convex.  When  the  eye  is 
fixed  upon  distant  objects  this  tendency  is  held  in  check 
through  the  traction  exerted  upon  the  lens  capsule  by 
the  zonule  of  Zinn.  The  tension  of  the  zonule  is  con- 
trolled by  the  action  of  the  ciliary  muscle.  When  this 
muscle  is  at  rest  the  tension  of  the  zonule  is  at  the  max- 


Fig.  1 54. — Changes  in  the  conformation  of  the  lens  during  accommodation. 
The  solid  white  outline  of  the  lens,  /,  shows  its  form  when  the  zonule,  or 
suspensory  ligament,  is  tense.  The  dotted  line  shows  the  increased  curva- 
ture of  the  anterior  surface  during  accommodation,  and  its  advancement  into 
the  anterior  chamber,  a.  z  is  the  suspensory  ligament;  m,  the  ciliary  muscle; 
and  /,  the  iris  (Landolt). 


imum;  when  it  contracts  the  tension  is  lessened.  The 
adjustment  of  the  eye  for  the  sharp-seeing  of  near  ob- 
jects is  brought  about,  then,  by  the  contraction  of  the 
ciliary  muscle,  which  relaxes  the  zonule  and  permits 
the  lens  to  become  more  convex  (Fig.  154).  The  exact 
degree  of  relaxation  of  the  zonule  necessary  to  produce 
the  required  change  in  the  focus  of  the  eye  is  learned 
through  experience,  and  varies  in  different  individuals, 
being  markedly  influenced  by  age. 


ANOMALIES    OF    ACCOMMODATION.  42/ 

From  this  description  it  is  evident  that  the  ability  of 
the  eye  to  accommodate  itself  for  different  distances 
may  be  impaired  in  any  one  of  several  ways:  The  lens 
may  lose,  to  a  greater  or  less  degree,  its  elasticity,  its 
tendency  upon  relaxation  of  the  zonule  to  become  more 
convex.  It  may,  as  a  congenital  fault,  possess  this  ten- 
dency to  a  subnormal  degree.  The  ciliary  muscle  may 
lose  its  power,  may  become  paralyzed,  or  it  may  become 
spasmodically  contracted,  or  it  may  be,  congenitally, 
weak  and  inefficient.  All  of  these  conditions  are  en- 
countered, and  each  of  them  produces  a  definite  dis- 
turbance in  the  accommodative  power  of  the  eye. 

The  first-mentioned  condition — the  loss  of  elasticity 
of  the  lens — occurs  in  every  eye  as  a  result  of  advancing 
age,  and,  when  it  has  reached  a  certain  degree,  con- 
stitutes the  fault  known  as  presbyopia  or,  popularly,  as 
old-sightedness.  The  second  and  last  conditions — con- 
genital inelasticity  of  the  lens,  and  congenital  inef- 
ficiency of  the  ciliary  muscle — are  of  not  infrequent  oc- 
currence, and,  existing  separately  or  conjointly,  give 
rise  to  the  anomaly  which  I  have  called  "subnormal 
accommodative  power."  The  third  condition — par- 
alysis of  the  ciliary  muscle — may  occur  suddenly  at  any 
time  of  life,  and  is  oftenest  due  to  syphilis  or  to  diph- 
theria. The  fourth  condition — spasm  of  the  ciliary 
muscle — is  met  with  occasionally  as  a  complication  in 
astigmatism  and  other  refractive  errors,  but  is  of  less 
frequent  occurrence  than  some  authorities  would  have 
us  believe. 

Presbyopia  (Old-sightedness). — As  a  result  of  its 
growth  and  the  sclerosis  of  its  older  central  fibers, 
which  in  time  come  to  form  the  hard  nucleus  character- 
istic of  the  senile  lens  (see  Chap.  IX),  the  crystalline  lens 
gradually   loses   its   elasticity,  its   capacity  to   become 


428  PREVALENT    DISEASES    OF    THE     EYE. 

more  convex  upon  relaxation  of  the  zonule.  This  dimi- 
nution of  elasticity  begins  to  manifest  itself,  as  has  been 
mentioned  already,  very  early  in  life,  even  in  childhood; 
but  usually  does  not  become  sufficiently  marked  to 
cause  inconvenience  until  about  the  forty-fifth  year, 
when  it  interferes  with  the  sharp-seeing  of  near  objects, 
as  in  reading,  sewing,  and  the  like.  Its  gradual  devel- 
opment also  lessens  the  ability  of  the  eye  to  cope  with 
refractive  faults,  and  so,  if  these  are  present,  may  lead, 
as,  for  example,  in  hypermetropia,  to  indistinctness  of 
distant  as  well  as  of  near  vision. 

With  the  advent  of  presbyopia  the  complaint  is 
often  heard  that  the  light,  especially  the  light  which  one 
has  been  in  the  habit  of  reading  or  sewing  by  at  night,  is 
not  as  good  as  it  formerly  was,  or  that  the  newspaper 
is  not  as  well  printed  as  it  used  to  be.  The  thread- 
ing of  a  needle  becomes  a  difficult  task,  and  the 
printed  page  or  the  sewing  is  held  inconveniently  far 
away  from  the  eyes.  If  these  hints  are  acted  upon, 
and  the  needed  glasses  procured,  satisfactory  and 
comfortable  near  vision  is  obtained  at  once;  but  if  the 
individual,  as  often  happens,  continues  to  struggle 
along  without  their  help,  hoping  to  avoid,  or  at  least 
postpone,  this  confession  of  advancing  years,  the  strain 
upon  the  eyes  soon  begins  to  tell,  and  asthenopic  symp- 
toms, or  headaches,  perhaps,  manifest  themselves. 

In  rare  instances  the  emmetropic  eye  retains  its  ability 
to  see  near  objects  distinctly  considerably  beyond  the 
usual  presbyopic  age;  but,  nearly  always,  when  this 
ability  is  present  after  the  forty-seventh  or  forty-eighth 
year,  it  will  be  found  that  one  or  both  eyes  are  myopic, 
and  only  exceptionally  are  such  persons  not  helped  by 
properly  adjusted  glasses,  for  only  exceptionally  does 
it  happen  that  the  myopia  is  just  of  the  requisite  degree 


ANOMALIES    OF    ACCOMMODATION.  429 

I  to  neutralize  the  presbyopia.     The  failure  of  near  vision 
'  before  the  forty-fifth  year  commonly  indicates  the  exist- 
ence of  hypermetropia  or,  perhaps,  of  hypermetropic 
astigmatism. 

Treatment. — There  is  but  one  way  to  deal  with  pres- 
byopia, and  that  is  by  giving  the  needed  glasses.  There 
is  no  warrant  for  the  claim,  put  forth  by  unprincipled 
quacks,  that  it  can  be  "cured,"  or  even  that  its  develop- 
ment can  be  postponed,  by  such  procedures  as  massage, 
the  use  of  "eye-cups,"  and  the  like. 

There  is  a  common  belief  that  in  the  selection  of 
glasses  for  "  old-sight "  the  services  of  the  oculist  may  be 
dispensed  with;  that  they,  at  all  events,  can  be  "  fitted" 
by  any  one  who  "carries  a  stock"  of  spectacles,  or  can 
be  chosen  with  safety  by  the  individual  himself.  The 
fallaciousness  of  this  view  can  not  be  too  emphatically 
insisted  upon.  In  prescribing  glasses  for  presbyopia 
one  often  has  to  take  into  account  unsuspected  refractive 
faults,  such  as  astigmatism  or  anisometropia.  The 
muscle-balance  also  has  to  be  considered,  and  the  in- 
fluence w^hich  the  glasses  that  seem  to  be  indicated  exert 
upon  it.  The  neglect  of  these  points,  which  fall  defi- 
nitely within  the  province  of  the  medical  specialist, 
gives  rise  to  much  unnecessary  discomfort,  and  not  in- 
frequently to  the  more  serious  consequences  apt  to  fol- 
low long-continued  eye-strain. 

It  should  be  borne  in  mind  that  presbyopia  is  a  pro- 
gressive condition,  and  that  the  glasses  prescribed  for 
its  correction  must  be  increased  in  strength  from  time 
to  time.  Usually,  if  they  have  been  accurately  adjusted, 
they  afi'ord  the  needed  help  for  about  two  years;  but 
there  are  many  exceptions  to  this  rule,  in  some  instances 
a  change  being  called  for  sooner  than  this,  and  in  others 
not  so  soon.     After  the  seventieth  year  it  is  not  often 


430 


PREVALENT    DISEASES    OF    THE    EYE. 


necessary  to  increase  further  the  strength  of  the  glasses, 
for  by  this  time  the  eye  has  lost  entirely  its  power  of 
accommodation.  In  exceptional  instances,  with  the 
acquisition  of  so-called  "second  sight,"  which,  as  has 
been  explained,  is  usually  a  premonitory  symptom  of 
developing  cataract,  the  glasses  previously  worn  have  to 
be  considerably  weakened,  or  may  even  be  put  aside 
altogether. 

In  presbyopia,  if  glasses  are  required  for  distant  vision 
as  well   as   for  near,  it   is  commonly  best   to   prescribe 


V 


Fig.  155. — Cemented  bifocal  lens. 
B,  Correction  for  distant  vision;  A, 
"lenticular,"    added  for  near  vision. 


Fig.  156. — "Invisible"  bi- 
focal lens.  The  "lenticular," 
which  is  countersunk,  is  made 
of  glass  having  a  very  high  in- 
dex of  refraction. 


bifocal  lenses  (Figs.  155  and  156),  as  this  does  away 
with  the  necessity  for  two  pairs  of  glasses  and  the  in- 
convenience of  having  to  change  frequently  from  one  to 
the  other.  At  first  such  lenses  often  prove  annoying; 
but  in  a  short  time  the  eyes  become  accustomed  to  them, 
and  they  afford  much  comfort. 

Paralysis  of  the  Ciliary  Muscle. — The  most  com- 
mon causes  of  this  anomaly,  as  has  been  stated,  are 
diphtheria  and  syphilis.  Other  conditions  which  may 
give  rise  to  it  are  affections  of  the  central  nervous 
system — tabes  dorsalis,  especially — influenza,  diabetes. 


ANOMALIES    OF    ACCOMMODATION.  43I 

ptomaine  poisoning,  and  contusion  of  the  eyeball.  It  is 
a  prominent  symptom,  too,  in  poisoning  by  belladonna 
(I  have  observed  it  in  one  instance  in  a  susceptible  in- 
dividual from  the  application  of  a  belladonna  plaster); 
and  it  is  to  be  remembered  that  it  is  sometimes  due  to 
the  accidental  and  unconscious  application  of  atropin 
to  the  eye,  as  in  an  instance  which  came  under  my  obser- 
vation recently  where  a  physician  rubbed  one  of  his 
eyes  with  his  finger  after  handling  a  hypodermic  tablet 
of  atropin  and  morphin. 

Not  infrequently  paralysis  of  the  ciliary  muscle  is 
accompanied  by  paralysis  of  the  sphincter  pupillae  and 
consequent  mydriasis.  This  is  more  apt  to  be  the  case 
when  the  paralysis  is  of  syphilitic  origin  or  when  it  oc- 
curs in  the  course  of  tabes.  It  happens  less  often  in 
post-diphtheritic  paralysis.  In  cases  due  to  acquired 
syphilis  it  is  not  uncommon  to  find  not  only  the  sphincter 
pupillae  implicated,  but  all  the  extraocular  muscles 
supplied  by  the  third  nerve.  In  post-diphtheritic  cyclo- 
plegia  both  eyes  are  usually  involved,  while  cases 
dependent  upon  syphilis  are  commonly  unilateral. 

The  prominent  symptom  is  impairment  of  sight, 
which  usually  manifests  itself  suddenly.  In  emme- 
tropic eyes  only  near  vision  is  affected;  but  both  far  and 
near  vision  are  impaired  in  eyes  that  are  hypermetropic, 
because  such  eyes  require  an  effort  of  accommodation 
to  see  distinctly  even  distant  objects.  If  the  paralysis 
is  complete,  ability  to  read  ordinary  print  is  lost.  The 
diagnosis  is  established  by  finding  that  a  convex  glass 
often  or  twelve  inches  focus  enables  fine  print  to  be  read 
with  ease. 

The  prognosis,  as  a  rule,  is  favorable,  especially  in 
the  post-diphtheritic  cases,  which  commonly  recover 
within  a  few  weeks.     The  most  unfavorable  cases  are 


432  PREVALENT    DISEASES    OF    THE    EYE. 

those  which  are  dependent  upon  disease  of  the  central 
nervous  system. 

Treatment. — This  necessarily  depends  upon  the  pri- 
mary cause  of  the  affection.  In  post-diphtheritic  cases 
and  in  cases  following  influenza  tonics  containing  iron 
and  quinin,  and  especially  strychnin,  are  indicated.  In 
cases  of  luetic  origin  potassium  iodid,  in  generous  doses, 
and  strychnin  are  the  most  useful  remedies.  Local 
remedies  are  of  but  little  value,  though  eserin,  in  weak 
solution,  is  usually  commended. 

Spasm  of  the  Ciliary  Muscle  (Spasm  of  Accom- 
modation).— The  most  typical  spasm  of  the  ciliary 
muscle  is  that  which  is  produced  by  the  action  of  eserin 
upon  the  eye.  The  contraction  of  the  muscle  causes  a 
marked  lessening  of  the  tension  of  the  zonule  of  Zinn, 
which,  in  persons  who  have  not  yet  reached  the  presby- 
opic age,  is  attended  by  an  exceptional  increase  in  the 
convexity  of  the  crystalline  lens.  This  results  in  the 
production  of  a  transient  myopia,  the  degree  depending 
upon  the  age  of  the  individual  and  the  strength  of  the 
eserin  solution  employed. 

Exceptionally,  something  equivalent  to  this  occurs 
in  ametropic  eyes  which,  without  suitable  glasses,  have 
been  strained  by  much  near  work.  It  is  more  prone  to 
occur  in  astigmatic  eyes,  particularly  in  astigmatism 
against  the  rule,  or  when  the  astigmatism  is  complicated 
by  insufficiency  of  the  internal  recti  muscles.  It  is 
usually  attended  by  marked  asthenopic  symptoms,  and 
not  infrequently  the  existence  of  a  low  grade  of  choroido- 
retinitis  is  revealed  by  the  ophthalmoscope.  It  neces- 
sarily masks  the  true  refractive  condition,  causing 
hypermetropic  astigmatism  and  even  considerable  de- 
grees of  hypermetropia  to  simulate  myopia,  and  exag- 
gerating any  real  myopia  that  may  be  present. 


ANOMALIES    OF    ACCOMMODATION.  433 

Treatment. — The  muscle-balance  in  far  and  near 
vision  having  been  determined,  a  cycloplegic  (atropin  or 
hyoscyamin)  should  be  prescribed.  In  most  instances 
this  will  quickly  overcome  the  ciliary  spasm,  though 
exceptionally  its  use  may  have  to  be  continued  for  some 
days  before  this  is  accomplished.  As  soon  as  this  has 
been  brought  about,  a  careful  measurement  of  the  re- 
fractive condition  of  the  eyes  should  be  made,  and 
glasses,  usually  for  constant  wear,  should  be  ordered.  If 
the  choroido-retinitis  is  marked  in  degree,  a  period  of 
abstinence  from  near  use  of  the  eves  should  be  insisted 
upon,  and  a  lotion  of  opium  and  boracic  acid,  to  be  em- 
ployed until  all  symptoms  of  irritation  have  subsided, 
should  be  prescribed. 

Subnormal  Accommodative  Power. — In  a  paper 
published  in  the  ''Transactions  of  the  American  Oph- 
thalmological  Society,"  in  1891,  I  described  a  condition 
which  I  believed  to  be  a  not  infrequent  cause  of  asthen- 
opia in  young  persons,  and  for  which  I  proposed  the 
name  "Subnormal  accommodative  power."  Although 
the  detection  and  correction  of  this  defect  can  hardly  be 
said  to  fall  withm  the  provmce  of  the  general  practi- 
tioner, I  may,  perhaps,  be  excused  for  going  somewhat 
into  detail  in  describing  it. 

The  characteristic  symptoms  of  this  condition,  as 
set  forth  in  my  paper,  are  quite  different  from  those  of 
presbyopia.  There  is  no  complaint  of  indistinctness 
of  near  vision,  but  of  asthenopia  and  not  infrequently  of 
headache.  The  underlying  cause  in  most  instances 
was  assumed  to  be  a  congenital  insufficiency  of  the 
ciliary  muscle.  A  congenital  rigidity,  or  lack  of  elas- 
ticity, of  the  crystalline  lens  would  account  for  the 
condition  as  satisfactorily.  The  anomaly  may  exist  in- 
dependently of  any  other  fault  of  the  eye,  or  may  compli- 
28 


434  PREVALENT    DISEASES    OF    THE    EYE. 

cate  other  errors,  refractive  or  muscular.  The  early 
development  of  presbyopia  occasionally  observed  i-n 
emmetropic  individuals  is  one  of  its  manifestations. 

Its  existence  is  not  to  be  determined  by  the  tests  em- 
ployed in  presbyopia, — for  the  finest  print  can  be  read 
with  facility  and,  for  a  short  while,  at  least,  at  as  near  a 
point  as  the  age  of  the  individual  would  lead  one  to  ex- 
pect,— but  is  demonstrated  by  a  lack  of  accordance  be- 
tween the  lateral  muscle-balance  in  far  and  in  near 
vision,  as  shown  by  the  vertical  diplopia  test  ot  von 
Graefe. 

This  test,  in  eyes  that  are  in  every  way  normal,  shows 
an  orthophoric  muscle-balance  in  distant  vision,  but 
at  the  reading  distance  shows  an  exophoria  of  from  3° 
to  5°.  Indeed,  whatever  the  muscle-balance  in  distant 
vision  may  be,  unless  certain  modifying  conditions  to 
be  described  presently  exist,  the  test  will  show  in  near 
vision  a  difference,  in  the  sense  of  exophoria,  of  3°  to  5°. 
For  example,  if  an  esophoria  at  20'  of  5°  is  shown, 
orthophoria  or,  at  most,  an  esophoria  of  1°  or  2°  should 
be  found  at  13''.  If,  on  the  other  hand,  an  exophoria  of 
5°  is  shown  in  distant  vision,  8°  to  10°  of  exophoria  may 
be  predicted  in  near  vision. 

A  difference  between  the  far  and  near  muscle-bal- 
ance, in  the  sense  of  exophoria,  appreciably  greater 
than  5°  indicates  that  the  convergence  effort  is  not  sup- 
ported, as  it  is  under  normal  conditions,  by  a  corre- 
sponding accommodative  effort.  This  is  what  happens 
in  uncorrected  myopia,  and  it  explains  the  excess  of  exo- 
phoria at  the  reading  distance  characteristic  of  this  de- 
fect. On  the  other  hand,  a  difference  appreciably  less 
than  3°  indicates  that  an  unusual  accommodative  effort 
is  being  put  forth,  an  effort  in  excess  of  the  convergence 
effort  which  normally  should  accompany  it. 


ANOMALIES    OF    ACCOMMODATION.  435 

A  typical  example  of  this  condition  is  shown  when  a 
cycloplegic  has  been  used,  and  the  eyes  have  not  fully 
recovered  from  its  influence.  If  under  such  circum- 
stances, even  when  the  accommodation  has  recovered 
sufficiently  to  enable  fine  print  to  be  read,  a  test  of  the 
near  muscle-balance  be  made  by  von  Graefe's  method, 
a  result  will  be  obtained  very  different  from  that  shown 
by  the  same  test  before  the  cycloplegic  was  used.  In- 
stead of  an  exophoria  of  3°  or  4°  or  5°,  the  test  will  show 
no  exophoria  at  all,  or,  at  all  events,  several  degrees  less 
than  was  found  previously.  The  meaning  of  this  is 
that  the  still  somewhat  enfeebled  ciliary  muscle  requires 
excessive  stimulation  to  enable  it  to  perform  the  work 
required  of  it,  and  that,  because  of  the  intimate  relation 
which  exists  between  the  accommodative  effort  and  the 
convergence  effort,  this  is  necessarily  accompanied  by 
a  corresponding  stimulation  of  the  conjointly  acting 
interni. 

No  better  illustration  than  this  could  be  offered  of 
what  occurs  in  the  condition  for  which  I  have  suggested 
the  name  subnormal  accommodative  power.  In  the 
one  case  we  have  a  transient  enfeeblement  of  the  ciliary 
muscle;  in  the  other,  a  ciliary  muscle  congenitally  weak, 
or,  what  amounts  to  the  same  thing,  an  inelastic  crys- 
talline lens,  to  cope  with  which  demands  inordinate 
action  upon  the  part  of  the  normal  ciliary  muscle;  but, 
so  far  as  the  muscle-balance  test  in  near  vision  is  con- 
cerned, the  result  is  the  same  in  each. 

Asthenopic  symptoms,  then,  manifest  themselves  in 
subnormal  accommodative  power,  as  they  usually  do 
when  the  normal  parallelism  between  the  two  functions 
is  disturbed,  because  the  accommodative  effort  is  in 
excess  of  the  convergence  effort. 

The  rule  for  the  detection  of  subnormal  accommoda- 


436  PREVALENT    DISEASES    OF    THE     EYE. 

tive  power,  deducible  from  what  has  gone  before,  is 
this:  Ascertain^  by  the  vertical  diplopia  test,  the  muscle- 
balance  in  far  and  in  near  vision.  If  the  latter  does  not 
show  a  difference,  in  the  sense  of  exophoria,  of  at  least  2°, 
the  existence  of  subnormal  accommodative  power  is  in- 
dicated. It  is  well  to  make  the  test  both  with  and  with- 
out correction  of  any  refractive  fault  that  may  be  pres- 
ent; but  the  result — the  difference  between  the  far  and 
near  muscle-balance — is  usually  the  same  under  both 
conditions.  In  applying  the  test  one  should  be  careful 
to  exclude  the  possible  influence,  such  as  has  been  de- 
scribed, of  a  cycloplegic.  As  to  this,  it  may  be  well  to 
state,  my  experience  shows  that  for,  at  least,  eight  days 
after  the  discontinuance  of  a  two-grain  solution  of 
hyoscyamin  hydrobromate  the  result  of  the  test  is 
almost  sure  to  be  misleading. 

Treatment. — It  is  manifest  that  we  have  in  convex 
glasses  the  means  of  getting  rid  of  the  unpleasant  con- 
sequences of  subnormal  accommodative  power.  In 
uncomplicated  cases,  that  is  to  say,  in  cases  in  which  no 
refractive  or  other  muscular  fault  exists,  they  will  be  re- 
quired for  near  vision  only.  Under  such  circumstances, 
the  strength  of  the  glass  needed  is  easily  determined  by 
following  this  simple  rule:  Ascertain  by  trial  the  weakest 
convex  spherical  glass  that  tvill give,  at  13'',  the  minimum 
amount  of  normal  exophoria  (2°  to  3°),  and  prescribe  this 
for  systematic  use  in  near  vision.  Should  the  strength  of 
this  glass  be  so  considerable  as  to  bring  the  binocular  far 
point  inconveniently  close  to  the  eyes,  reduce  it,  and  add 
esophortc  prisms  of  such  strength  as  will  give  the  re- 
quired exophoria. 

In  complicated  cases  the  correction  needed  for  distant 
vision  should  be  determined  by  the  usual  tests,  and  then, 
with  this  correction,  the  test  for  subnormal  accommoda- 


ANOMALIES    OF    ACCOMMODATION.  437 

tive  power  should  be  employed  in  the  manner  just  de- 
scribed, convex  glasses  or,  possibly,  sphero-prisms,  being 
added  until  the  required  exophoria  at  the  reading  dis- 
tance is  obtained.  This,  of  course,  involves  the  neces- 
sity, in  such  cases,  for  two  pairs  of  glasses,  one  for  far, 
the  other  for  near,  vision,  unless,  as  a  matter  of  con- 
venience, bifocal  lenses  are  preferred. 

As  set  forth  in  a  recent  paper,*  published  in  the 
"Transactions  of  the  American  Ophthalmological  So- 
ciety" for  1904,  and  in  the  "Johns  Hopkins  Hospital 
Bulletin"  for  January,  1905,  the  results  which  I  have 
obtained  in  this  condition  of  subnormal  accommodative 
power  by  following  the  rules  just  given — prescribing  at 
times  for  young  asthenopic  emmetropes  convex  glasses 
of  considerable  strength  for  near  vision,  and  for  young 
hypermetropes  stronger  glasses  for  near  than  for  distant 
vision,  and  occasionally  combining  with  these  esophoric 
prisms — have  been  so  eminently  satisfactory,  that  the 
practice  has  become  as  much  a  matter  of  course  with  me 
as  the  correction  of  astigmatism  or  of  hypermetropia 
itself. 

*  "  The  Importance  of  Testing  the  Ocular  Muscle-balance  for 
Near,  as  well  as  for  Distant  Vision." 


CHAPTER  XII. 
MUSCULAR  ANOMALIES  OF  THE  EYES. 

The  muscular  anomalies  of  the  eyes  are  divisible  into 
two  major  groups — manifest  muscular  anomalies,  and 
latent  muscular  anomalies.  The  first  group  comprises 
the  several  varieties  of  squint — convergent,  divergent, 
and  vertical;  the  second  group,  the  different  varieties  of 
heterophoria,  or  insufficiency  of  the  ocular  muscles — 
esophoria,  exophoria,  and  hyperphoria.  The  essential 
difference  betv^een  the  tw^o  is  that  in  the  one  case 
there  is  a  sacrifice  of  binocular  vision,  while  in  the  other 
binocular  vision  is  maintained,  but  only  at  the  cost  of  a 
constant  struggle  against  an  ever-present  tendency  to 
squint. 

Again,  the  muscular  anomalies  of  the  eyes  may  be 
divided,  with  reference  to  their  etiology,  into  those  of 
paralytic  origin,  those  of  congenital  origin,  and  those 
dependent  upon  defects  in  the  conformation  of  the  eye 
— upon  refractive  errors. 

The  anomalies  of  paralytic  origin  commonly  belong 
to  the  first  major  group,  though,  as  improvement  in  the 
palsy  occurs,  the  squint  may  disappear,  and  they  mav 
pass  over  into  the  second  group,  to  remain  there  for  a 
shorter  or  longer  time  or,  it  may  be,  permanently.  The 
anomalies  of  congenital  origin,  for  the  most  part,  belong 
to  the  second  group,  though,  exceptionally,  they  may 
give  rise  to  actual  squint.  The  anomalies  due  to  errors 
of  refraction  constitute  a  very  considerable  part  of  both 
major  groups. 

438 


MUSCULAR   ANOMALIES    OF    THE    EYES.  439 

The  manifest  muscular  anomalies — the  actual  squints 
— are  not,  in  themselves,  provocative  of  eye-strain,  of 
asthenopia,  but  are  of  moment  chiefly  because  of  the 
deformity  which  attends  them,  and  because  the  squint- 
ing eye  usually  becomes  rapidly  amblyopic.  When  they 
are  of  paralytic  origin,  and,  therefore,  develop  suddenly,  ] 
they  are  also  commonly  attended  by  very  annoying  I 
diplopia  and  by  vertigo.  On  the  other  hand,  the  latejit 
anomalies,  while  they  have  no  cosmetic  significance,  are 
of  moment  because  of  the  marked  asthenopic  symptoms 
to  which  they  give  rise.  The  asthenopia  is  the  expres- 
sion of  the  constant  effort  required  to  maintain  binocular 
vision,  in  the  presence  of  a  disposition  to  squint;  the 
establishment  of  the  squint  means  the  abandonment  of 
this  eff^ort,  and  frequently  results  in  the  disappearance 
of  the  asthenopia. 

Squints  provoked  by  errors  of  refraction  are  lateral 
squints,  and,  according  to  the  nature  of  the  refractive 
fault,  the  misdirected  eye  may  turn  in  or  out,  the  squint 
may  be  convergent  or  divergent.  Convergent  squints, 
as  has  been  explained  in  the  preceding  chapter,  are  usu- 
ally associated  with,  and  in  most  instances  are  depen- 
dent upon,  hypermetropia,  and  commonly  develop  in 
early  childhood.  Divergent  squints  are  oftenest  asso- 
ciated with  myopia,  and  may  develop  at  any  period  of 
life. 

Squints  due  solely  to  muscular  faults  of  congenital 
origin,  as  has  been  said,  are  rare;  but  when  such  mus- 
cular faults  happen  to  be  associated  with  refractive 
errors  they  may,  and  often  do,  play  an  important  part 
in  the  production  of  squint. 

Paralytic  squints  may  occur  at  any  age,  and,  depend- 
ing upon  the  muscle  involved,  the  squinting  eye  may 
turn  in  or  out,  upward  or  downward.     To  a  proper 


440 


I'REVALENT    DISEASES    OF    THE     EYE. 


comprehension  of  squints  of  this  character  familiarity 
with  the  nervous  supply  of  the  extrinsic  muscles  of  the 
eye  is  essential. 

MANIFEST  MUSCULAR  ANOMALIES. 
Paralytic  Squint. — It  will  be  recalled  that  no  less 
than  three  of  the  cranial  nerves  are  distributed  to  the 
extrinsic  ocular  muscles  (Fig.  157).     The  abducens,  or 


Fig.  157. — The  ocular  muscles — the  recti  muscles,  a,  b,  c,  d,  separated  from 
their  attachments  at  the  apex  of  the  orbit,  the  bony  attachment  of  the  inferior 
oblique  muscle  (/),  and  the  trochlea  of  the  superior  oblique  (e),  diagram- 
matically  represented  (Nunnelcy). 

sixth  nerve,  supplies  the  external  rectus;  the  trochlear,  or 
fourth  nerve,  the  superior  oblique;  and  the  oculomotor,  or 
third  nerve,  all  the  other  external  muscles  of  the  eyeball, 
as  well  as  the  levator  of  the  upper  lid,  the  ciliary  mus- 


MUSCULAR    ANOMALIES    OF    THE    EYES.  44I 

cle,  and  the  sphincter  pupillae.  From  this  it  follows 
that  but  a  single  muscle  is  affected  in  paralysis  of  the 
fourth  or  sixth  nerve,  but  that  many  are  involved,  or 
may  be  involved,  in  paralysis  of  the  third  nerve.  In 
complete  paralysis  of  any  one  of  these  three  nerves  a 
squint  develops,  and,  as  has  been  said,  is  attended  by 
very  annoying  diplopia.  If  the  paralysis  is  incom- 
plete, the  squint  and  the  diplopia  may  manifest  them- 
selves only  when  an  effort  is  made  to  turn  the  eyes 
in  the  direction  of  the  affected  muscle.  Under  any 
circumstances  the  diplopia  disappears  when  either 
.  eye  is  excluded  from  vision.  The  sudden  occurrence 
/  of  diplopia,  which  can  be  gotten  rid  of  by  the  exclusion 
*  of  one  eye,  is  an  almost  certain  indication  of  paraly- 
sis of  some  one  of  the  extrinsic  eye  muscles.  The 
squint  which  attends  the  paralysis  results,  as  a  matter 
of  course,  from  the  unrestrained  action  of  the  opponent 
muscle.  Paralytic  squints,  as  a  rule,  can  be  distin- 
guished from  concomitant  squints  (those  due  to  refrac- 
tive errors)  by  the  fact  that  the  squint  increases  in  degree 
when  the  eyes  are  turned  tow^ard  the  faulty  muscle. 
An  inability  to  rotate  the  affected  eye  in  the  direction  of 
this  muscle  is  also  usually  evident;  though,  in  incom- 
plete paralysis,  this  is  not  always  demonstrable. 

Paralysis  of  the  ocular  muscles  (Fig.  158)  arises  from 
a  variety  of  causes,  and  may  be  central  or  peripheral  in 
its  origin.  Acquired  syphilis  is  one  of  the  commonest. 
Among  other  causes  may  be  mentioned  disease  of  the 
central  nervous  system,  locomotor  ataxia,  for  example, 
rheumatism,  influenza,  diphtheria  and  other  acute  affec- 
tions, diabetes,  renal  and  vascular  disease,  "cold," 
traumatism,tumors,  or  other  coarse  pathological  changes, 
within  the  cranial  cavity,  and  similar  pathological  pro- 


442 


PREVALENT    DISEASES    OF    THE     EYE. 


cesses  involving  especially  the  apex  of  the  orbit,  through 
which  the  nerves  pass  in  their  course  to  the  eye. 

In  paralyses  of  intracranial  origin,  the  lesion  may  be 
cortical,  or  it  may  involve  the  association  centers,  the 
nerve  nuclei,  the  fibers  which  connect  these  centers, 
or,  finally,  the  nerve-trunks  in  their  course  along  the 
base  of  the  brain.  Although  the  lesion  may  develop  as 
a  primary  affection,  it  is  much  more  frequently  the  re- 


Fig.  158. — Lateral  view  of  the  ocular  muscles  (Nunneley).  The  external 
rectus  (h)  is  divided,  so  as  to  show  the  attachments  of  the  oblique  muscles 
{i,  k)  to  the  eyeball.  The  attachments  of  the  four  recti  muscles  {e,  /,  g,  h), 
the  superior  oblique  {i),  and  the  levator  palpebrae  {d)  at  the  apex  of  the  orbit 
are  also  shown. 

suit  of  pathological  processes  in  neighboring  structures, 
which  involve  secondarily,  by  compression  or  otherwise, 
the  nerves  or  their  nuclei.  In  orbital  paralyses,  the 
nerve-lesion  may  be  primary,  the  result  of  exposure  to 
cold,  for  example,  or  it  may  be  secondary  to  other  dis- 
ease, such  as  periostitis  or  gumma  at  the  apex  of  the 
orbit. 

Paralysis  of  the  External  Rectus  Muscle  (Paralysis  of 
the  Sixth  Nerve). — This  is  the  commonest  of  the  ocular 


MUSCULAR    ANOMALIES    OF    THE    EYES.  443 

palsies.  The  lesion  is  usually  orbital — an  inflammation 
of  the  nerve  itself  or  of  its  sheath — and  is  commonly  the 
result  of  exposure  to  cold.  If  the  paralysis  is  complete, 
there  will  be  an  easily  recognized  inward  squint  of  the 
affected  eye  (Fig.  159),  which  will  become  more  pro- 
nounced if  an  effort  is  made  to  rotate  the  eyes  in  the 
direction  of  the  paralyzed  muscle.  Slight  pain  in  the 
region  of  the  orbit  or  one-sided  headache  may  be  com- 
plained of,  but  the  chief  complaint  will  be  of  diplopia, 
which  is  commonly  attended  by  vertigo  and  not  infre- 
quently by  nausea.     If  the  paralysis  is  incomplete,  the 


Fig.    159. — Convergent  strabismus  (Dalrvmple). 

squint  will  be  evident,  and  the  diplopia  will  manifest 
itself,  only  when  the  eyes  are  turned  toward  the  affected 
muscle.  Closure  of  either  eye  will  cause  the  diplopia  to 
disappear.  The  affection  is  nearly  always  unilateral,  and 
the  prognosis  is  distinctly  favorable. 

Treatment. — The  most  efficacious  remedy  is  potas- 
sium iodid  in  moderate — five-  to  ten-grain — doses. 
In  conjunction  with  this  strychnin  may  be  given.  The 
application  of  a  blister  to  the  temple  has  also  seemed 
to  me  to  be  beneficial.  In  order  to  get  rid  of  the  annov- 
ance  caused  by  the  diplopia,  the  affected  eye  should  be 
excluded  from  vision  by  means  of  a  patch  or  a  ground 
glass. 


444  PREVALENT    DISEASES    OF    THE     EYE. 

Paralysis  of  the  Superior  Oblique  Muscle  {Paralysis 
oj  the  Fourth  Nerve). — This  is  much  less  common  than 
paralysis  of  the  external  rectus,  and  is  not  so  easily  diag- 
nosticated. Although  it  may  arise  from  any  of  the 
causes  mentioned  as  capable  of  producing  ocular  palsies, 
in  its  etiology  and  pathology  it  usually  resembles  the 
affection  just  described,  and  the  prognosis  is  equally 
favorable. 

As  the  action  of  the  superior  oblique,  besides  rotating 
the  eye  about  its  sagittal  axis  so  that  the  upper  extremity 
of  the  vertical  meridian  is  inclined  invNard,  is  to  turn 
the  eye  downward  and  outward,  the  diplopia  and  squint 
which  attend  paralysis  of  this  muscle  are  more  marked, 
or  mav  occur  only,  on  looking  down  As  this  is  true 
also  of  paralysis  of  the  inferior  rectus,  the  differentiation 
of  the  two  conditions  is  to  be  made  only  by  carefully 
taking  into  account  the  character  of  the  diplopia, 
whether  the  images  are  "crossed"  or  "homonymous," 
and  whether  the  "false  image"  tilts  toward  or  away 
from  the  median  line;  but  as  such  tests  do  not  fall 
within  the  province  of  the  general  practitioner,  a  de- 
tailed description  of  them  may  be  omitted,  especially  as 
the  treatment  of  the  two  conditions  is  essentially  the 
same. 

Treatment.  — The  therapeutic  measures  recommended 
in  paralysis  of  the  external  rectus  are  indicated. 

Paralysis  of  the  0 c ulo motor i us  or  Third  Nerve. — Next 
to  paralvsis  of  the  sixth  nerve,  this  is  the  commonest  of 
the  ocular  paralyses.  It  is  oftenest  dependent  upon 
acquired  syphilis,  is  occasionally  bilateral,  and  is  not 
infrequently  accompanied  by  palsy  of  other  motor 
nerves  of  the  eye.  When  all  the  branches  of  the  nerve 
are  involved  a  striking  and  very  characteristic  picture 
is  exhibited.    From  loss  of  power  of  the  levator  palpebrae 


MUSCULAR    ANOMALIES    OF    THE    EYES.  445 

-  the  upper  lid  droops,  and  cannot  be  elevated  (ptosis) 
(see  Fig.  36).  The  pupil  is  semidilated  and  near  vision 
greatly  impaired,  because  the  sphincter  pupillae  and  the 
muscle  of  accommodation  are  paralyzed;  and,  as  all 
the  extrinsic  eye-muscles,  except  the  external  rectus 
and  the  superior  oblique,  are  affected,  there  is  a  down- 
ward and  outward  squint,  with  inability  to  turn  the  eye 
upward,  inward,  or  directly  downward.  Diplopia  is 
not  complained  of  because  the  drooping  lid  excludes 
the  affected  eye  from  participation  in  vision;  it  becomes 
manifest,  however,  when  the  lid  is  held  up.  If  the 
fourth  and  sixth  nerves  are  also  involved  there  will  be 
inability  to  move  the  eye  in  any  direction,  and,  especially 
in  this  condition,  known  as  ophthalmoplegia  totalis, 
there  will  be  marked  exophthalmos,  since  the  eyeball 
is  deprived  of  the  restraining  influence  of  all  of  the  recti 
muscles. 

Not  infrequently  only  the  extrinsic  muscles  supplied 
by  the  third  nerve  are  affected,  and  the  intrinsic  mus- 
cles, the  sphincter  pupillae  and  the  ciliarv  muscle,  es- 
cape. This  type  of  paralysis,  known  as  ophthalmo- 
plegia externa,  is  necessarily  of  nuclear  origin,  and  finds 
its  explanation  in  the  fact  that  the  nuclei  for  the  sphinc- 
ter pupillae  and  the  ciliary  muscle  lie  appreciably  in  front 
of  those  for  the  extrinsic  muscles.  For  the  same  reason 
it  may  happen  that  the  extrinsic  muscles  escape,  while 
only  the  intrinsic  muscles  are  involved.  This  consti- 
.-  tutes  the  condition  known  as  ophthalmoplegia  interna, 
\  and  is  characterized  by  mydriasis  and  loss  of  power  of 
accommodation.  Diphtheria  is  oftenest  responsible  for 
this  type  of  ocular  paralysis,  which  has  been  considered 
in  the  preceding  chapter,  in  treating  of  "anomalies  of 
accommodation."  Isolated  paralysis  of  other  muscles 
supplied  by  the  third  nerve  is  observed,  but  more  rarely. 


446  PREVALENT    DISEASES    OF    THE     EYE. 

It  may  result  from  orbital  disease,  or  may  be  congenital 
in  origin.  Congenital  ptosis,  from  paralysis  or  imper- 
fect development  of  the  levator  palpebral  superioris 
(see  Fig.  35),  is  a  familiar  example.  It  is  usually  bilat- 
eral, and  is  at  times  accompanied  by  congenital  para- 
lysis of  the  superior  recti. 

The  prognosis  in  paralysis  of  the  third  nerve,  espe- 
cially when  the  affection  is  of  luetic  origin,  is  favorable, 
provided  the  requisite  therapeutic  measures  are  em- 
ployed without  delay. 

Treatmefjt. — Mercury  and  potassium  iodid  are,  of 
course,  the  chief  reliance  in  cases  due  to  syphilis,  and 
the  latter  is  useful  in  other  types  of  the  disease.  Strych- 
nin may  be  given  in  combination  with  either  of  these 
agents,  and  some  authorities  have  faith  in  the  efficacy 
of  electricity. 

■  Operative  procedures  for  the  correction  of  paralytic 
squints  and  acquired  ptosis  are  not  to  be  resorted  to 
hastily.  Indeed,  they  should  be  employed  only  after 
other  measures  have  been  tried  thoroughly,  and  have 
proved  of  no  avail. 

Conjugate,  or  Associated,  Ocular  Paralyses.— 
This  interesting  form  of  ocular  palsy  results  from 
lesions  which  involve  the  centers  for  the  associated 
movements  of  the  eyes — the  convergence  center,  for 
example,  which  presides  over  the  conjoint  action  of  the 
internal  recti  muscles,  or  the  center  which  controls 
the  conjoint  action  of  the  internal  rectus  of  one  eye 
and  the  external  rectus  of  the  other,  and  has  to.  do 
with  the  lateral  movements  of  the  eyes.  A  lesion 
of  the  first-named  center  will  annul  the  associated 
action  of  the  internal  recti,  though  these  same  muscles 
will  act  normally  in  rotating  the  eyes  to  the  right  or 
left.     On  the  other  hand,  a  lesion  of  the  center  for 


MUSCULAR    ANOMALIES    OF    THE    EYES.  447 

the  lateral  movements  of  the  eyes  will  prevent  their 
being  turned  tov^ard  the  affected  side,  though  the  con- 
vergence movement  remains  intact.  This  latter  con- 
dition usually  leads  to  a  more  or  less  marked  deflection 
of  the  eyes  toward  the  unaffected  side — conjugate  devi- 
ation of  the  eyes.  Conjugate  paralyses  are  usually  the 
result  of  destructive  lesions  of  the  brain,  particularly 
cerebral  hemorrhage. 

The  prognosis  depends  upon  the  seriousness  of  the 
cerebral  lesion,  to  which  the  treatment  is  to  be  directed. 

Nystagmus. — This  affection,  in  which  there  is  a 
rapid,  oscillatory  movement  of  the  eyes,  usually  lateral, 
but  more  rarely  vertical  or  rotary,  is  commonly  of  con- 
genital origin.  It  is  met  with  also  as  an  acquired  con- 
dition, and  then  usually  develops  in  infancy  or  early 
childhood.  An  interesting  form  of  acquired  nystagmus 
occurs  in  miners,  as  a  result  of  the  abnormal  conditions 
to  which  their  eyes  are  subjected. 

Congenital  nystagmus,  and  this  is  true  also  of  the 
nystagmus  acquired  in  early  childhood,  is  commonly 
associated  with  other  congenital  ocular  defects,  such  as 
zonular  cataract,  coloboma  of  the  choroid,  corneal 
opacities,  albinism,  refractive  errors  of  high  grade,  etc. 
Like  the  conjugate  paralyses  just  described,  this  affec- 
tion also  is  dependent  upon  an  abnormal  condition  of 
the  centers  which  preside  over  the  associated  move- 
ments of  the  eyes. 

Although  from  a  cosmetic  point  of  view  nystagmus 
is  of  moment,  it  seems,  of  itself,  except,  perhaps,  in  the 
case  of  miner's  nystagmus,  to  give  rise  to  no  subjective 
inconvenience.  It  may  be  added  in  parenthesis,  how- 
ever, that  it  is  the  bete  noire  of  the  ophthalmoscopist  and 
of  the  "  refractionist,"  so  called. 

Treatment. — Little  can  be  done  for  the  amelioration 


448  PREVALENT    DISEASES    OF    THE     EYE. 

of  congenital  or  early  acquired  nystagmus,  except  to 
correct  carefully  any  refractive  fault  that  may  be  pres- 
ent. Miner's  nystagmus  may  disappear  in  time  as  a 
result  of  a  change  of  occupation. 

Concomitant  Squint  (Strabismus  Concomitans). 
— A  concomitant  squint,  as  opposed  to  a  paralytic 
squint,  is  one  in  which  the  squint  remains  constant  in 
degree  in  whatever  direction  the  eyes  may  be  turned; 
that  is,  the  squinting  eye  always  follows  the  movements 
of  the  fixing  eye.  In  paralytic  squint,  as  has  been  ex- 
plained, this  is  not  the  case.  The  squinting  eye  does 
not  follow  in  all  directions  the  movements  of  the  fixing 
eye,  and  therefore  the  squint  varies  in  amount,  increas- 
ing when  the  eves  are  turned  in  the  direction  of  the 
paralyzed  muscle,  and  diminishing  or,  perhaps,  disap- 
pearing when  they  are  turned  in  the  opposite  direc- 
tion. 

The  misdirected  eye  in  concomitant  squint  may  turn 
in  or  out,  upward  or  downward,  or  it  may  squint  both 
vertically  and  laterally.  The  squint  mav  be  constant, 
or  it  may  be  inconstant,  or  periodic,  as  it  is  termed.  It 
may  affect  always  the  same  eye,  or  it  may  be  alternating 
■ — may  shift  from  one  eye  to  the  other.  It  is  never  bi- 
lateral, since  one  or  the  other  eye  must  necessarily  be 
directed  toward  the  object  regarded.  Diplopia  is  rarely 
complained  of  in  concomitant  squint,  because,  in  the 
first  place,  the  fault  usually  develops  in  early  childhood, 
and,  in  the  next  place,  in  the  young  the  habit  of  mentally 
suppressing  the  image  formed  in  the  squinting  eve  is 
very  quickly  acquired. 

Reference  has  already  been  made  to  the  causes  of 
concomitant  squint.  Enumerated  in  the  order  of  their 
importance,  they  are:  anomalies  of  refraction,  congen- 
ital  muscular   defects    (insuflSiciencies),  acquired   mus- 


MUSCULAR   ANOMALIES    OF    THE    EYES.  449 

cular  defects.  A  marked  difference  in  the  visual  acute- 
ness  of  the  two  eyes  also  tends  to  promote  the  develop- 
ment of  squint,  and  so  does  a  pronounced  difference  in 
their  refraction. 

Apart  from  the  deformity  which  attends  it,  the  most 
serious  consequence  of  concomitant  squint  is  the  ambly- 
opia of  the  squinting  eye  to  which  it  gives  rise.  It  is 
true,  there  are  those  who  contend  that  the  amblyopia 
nearly  always  found  in  the  squinting  eye  (in  non-alter- 
nating strabismus)  is  a  cause,  ratherthan  a  consequence, 
of  the  squint;  but,  to  my  mind,  the  evidence  to  the  con- 
trary is  so  strong  as  to  be  practically  conclusive.* 

It  is  a  mistake  to  designate,  as  most  writers  do,  the 
amblyopia  of  a  squinting  eye  as  "  amblyopia  exanopsia," 
for  it  is  essentially  different  in  its  origin  from  this  con- 
dition. As  an  example  of  true  amblyopia  exanopsia, 
or,  in  other  words,  of  amblyopia  from  non-use  of  an  eye, 
may  be  cited  the  impairment  of  vision  w^hich  results 
from  permitting  a  monocular,  congenital-  cataract  to 
remain  too  long  unoperated  upon.  Under  such  cir- 
cumstances, the  cataractous  eye  becomes  amblyopic 
simply  because  its  retina  and  optic  nerve  are  not  exer- 
cised as  they  should  be.  In  concomitant  squint  some- 
thing very  different  from  this  occurs.  In  order  to  get 
rid  of  the  diplopia,  which  at  the  outset  necessarily  mani- 
fests itself  each  time  that  the  as-yet-not-fully-estab- 
lished squint  recurs,  an  active  mental  effort  is  made  to 
suppress  the  image  formed  upon  the  retma  of  the  squint- 
ing eye;  and  in  the  young  this  effort  proves  so  successful 
that  in  a  comparatively  short  time  the  diplopia  disap- 

*  The  author's  views  upon  this  point,  and  the  grounds  upon  which 
they  are  hased,  are  set  forth  in  a  paper  "The  Amblyopia  of  Squinting 
Eyes:  Is  it  a  Determining  Cause  or  a  Consequence  of  the  Squint?" 
pubHshed  in  the  "Medical  News"  of  September  4,  1886,  and  in  the 
"Trans,  of  the  American  Ophthalmological  Society"  for  1886. 
29 


450  PREVALENT    DISEASES    OF    THE     EYE. 

pears,  and  concurrently  with  this  the  sight  of  the  squint- 
ing eyes  becomes  markedly  impaired. 

As  pointed  out  in  the  paper  to  which  reference  has 
been  made,  the  regional  character  of  the  amblyopia 
found  in  squinting  eyes  is  very  significant,  and  affords 
strong  evidence  in  support  of  the  view  that  it  is  an  ac- 
quired, and  not  a  congenital,  condition,  and  that  it  is 
produced  in  the  manner  just   described. 

If  we  ask,  what  must  be  the  chief  sources  of  annoy- 
ance to  an  individual  who  has  just  begun  to  squint,  we 
must  conclude  that  he  has  two  especial  difficulties  to 
contend  with — one,  the  doubling  of  every  object  upon 
which  he  fixes  his  attention,  in  consequence  of  the 
"false"  position  of  the  retinal  image  of  this  object  in 
the  squinting  eye;  the  other,  the  confusion  of  vision 
which  must  result  from  the  images  of  different  objects 
falling  upon  the  macular  region  of  the  two  eyes. 

To  get  rid  of  these  annoyances  he  has  a  twofold 
task  to  accomplish:  To  eliminate  the  diplopia, 
he  must  induce  that  part  of  the  retina  of  the 
squinting  eye  that  habitually  receives  the  false  image 
of  the  object  he  is  regarding  with  the  other  eye  not  to 
take  cognizance  of  this  image;  to  prevent  the  image  of 
some  object  which  he  is  not  regarding  from  being  (men- 
tally) superposed  and  fused  with  the  object  which  he  is 
regarding,  he  must  ignore  all  images  formed  upon  the 
macula  of  the  squinting  eve.  The  successful  accom- 
plishment of  this  task  will  result  in  the  production  of  an 
amblyopia  in  the  squinting  eye  regional  in  character — 
most  marked  (i)  in  the  neighborhood  of  the  macula  and 
(2)  in  that  portion  of  the  retina  which  receives  the  false 
image  of  the  object  regarded  by  the  properly  directed 
eye.  Now,  as  a  matter  of  fact,  the  amblyopia  found  in 
squinting  eyes  does  exhibit   just  these  characteristics. 


MUSCULAR    ANOMALIES    OF    THE    EYES.  45 1 

and  this  circumstance  seems  to  afford,  as  I  have  said, 
ahnost  conclusive  proof  that  the  defect  is  not  a  con- 
genital one,  but  is  a  product  of  the  squint.* 

Thi-s  question  of  the  origin  of  the  amblyopia  of  squint- 
ing eyes  is  one  not  merely  of  theoretical  interest,  but  of 
practical  importance;  for,  if  it  can  be  established  that 
the  amblyopia  is  a  consequence  of  the  squint,  the  advis- 
ability of  early  operation  would  hardly  be  open  to  doubt. 

It  is  a  fortunate  circumstance  when  a  squint  shows 
a  disposition  to  alternate,  or  when,  as  sometimes  happens, 
the  eye  which  squints  in  distant  vision  is  the  fixing 
eye  in  near  vision,  and  vice  versa;  for,  under  such  cir- 
cumstances, both  eyes  usually  retain  good  vision.  A 
marked  difference  in  the  refraction  of  the  two  eyes  also 
has  a  tendency  to  lessen  the  likelihood  of  the  squinting 
eye  becoming  amblyopic,  because  the  retinal  image  in 
this  eye,  being  ill-defined,  causes  less  annoyance,  and 
for  this  reason  is  not  so  energetically  "suppressed." 

Concomitant  squint  is  always  alternating  in  the  sense 
that  if  the  fixing  eye  is  covered  the  squint  shifts  to  this 
eye,  and  the  other  eye,  for  the  moment,  becomes  the 
fixing  eye.  It  is  true  the  fixation  with  this  eye  is  often 
uncertain,  and  may  be  eccentric,  because  of  its  regional 
amblyopia.     The    "secondary"    squint    thus    induced 

*  It  is  an  interesting  fact,  and  one  having  an  important  bearing 
upon  the  question  under  consideration,  that  when  a  squint,  which  for 
years  has  been  unattended  by  diplopia,  is  over-corrected  by  too  free 
tenotomizing — so  that,  for  example,  a  convergent  squint  is  converted 
into  a  divergent  one — a  persistent  and  annoying  diplopia  not  infre- 
quently manifests  itself.  The  explanation,  of  course,  is  that  owing  to 
the  change  in  the  direction  of  the  squint  the  false  image  now  falls  upon 
an  entirely  different  part  of  the  retina,  a  part  which  has  not  learned  to 
ignore  images  formed  upon  it,  and,  therefore,  is  not  amblyopic.  The 
diplopia  which  it  is  usually  possible  to  produce  in  a  strabismic  indi- 
vidual by  causing  the  false  image  of  a  candle  flame,  by  means  of  a 
prism,  to  fall  upon  an  unusual  part  of  the  retina  is  to  be  explained  in 
the  same  way,  and  is  equally  significant. 


452  PREVALENT    DISEASES    OF    THE     EYE. 

in  the  usually  properly  directed  eve  commonly  equals 
in  degree  the  "primary"  squint;  but,  especially  in  con- 
vergent strabismus,  it  is  not  infrequently  greater  in 
amount,  because  the  ciliary  muscle  of  the  squinting  e}'e 
is  not  exercised  as  habituallv  as  that  of  the  fixing  eve, 
and  must,  therefore,  put  forth  a  greater  effort  in  order 
to  obtain  a  sharply  defined  retinal  picture.  The  result 
is  the  same  when  the  refractive  error  is  considerably 
greater  in  the  squinting  eye.  On  the  other  hand,  when, 
as  is  seldom  the  case,  the  refractive  error  in  this  eve  is 
considerably  less  than  in  the  fixing  eye  the  secondary 
squint  may  be  less  than  the  primary. 

The  detection  of  a  pronounced  squint  is  not  a  difficult 
matter;  but,  if  one  relies  solely  upon  "appearances," 
it  is  easy  to  fall  into  error.  For  not  only  is  it  often  im- 
possible to  recognize  in  this  way  slight  degrees  of  squint, 
but  there  is  a  simulation  of  convergent  squint  in  myopia 
of  high  grade,  and  of  divergent  squint  in  hypermetropia 
of  like  character,  "calculated"  to  deceive  even  the  elect. 

The  "cover-test"  affords,  except  when  the  fault  is 
very  slight  in  degree,  a  trustworthy  means  of  determm- 
ing  the  existence  or  non-existence  of  squint,  and  it  is  not 
difficult  of  application.  The  patient,  with  both  eyes 
open,  is  directed  to  gaze  fixedly  upon  a  candle-flame 
ten  to  twenty  feet  away.  The  supposedly  fixing  eye  is 
then  covered  quickly  with  a  small  screen,  while  the  other 
eye  is  watched  closely  to  see  if  it  moves,  in  order  to  "  fix  " 
the  flame.  If  it  has  been  squinting  previously  it  is  ob- 
vious that  it  must  make  a  "movement  of  correction," 
as  it  is  termed,  in  order  to  look  directly  at  the  candle- 
flame.  In  very  low  degrees  of  squint  this  correcting 
movement  is  so  slight  that  it  may  be  difficult  to  detect; 
but,  except  under  such  circumstances,  it  is  easih'  ob- 
served, and  when  observed  the  existence  of  a  squint  is 


MUSCULAR   ANOMALIES    OF    THE    EYES.  453 

proved.  The  direction  of  the  movement  will  show  the 
character  of  the  squint — whether  it  is  convergent,  di- 
vergent, or  vertical. 

Convergent  Concomitant  Squint  or  Strabismus. — 
This  is  the  commonest  variety  of  concomitant  squint  (see 
Fig.  159).  It  nearly  always  develops  in  early  childhood, 
when  the  eyes  are  beginning  to  be  used  in  regarding 
near  objects,  and,  except  in  rare  instances,  it  is  found  in 
association  with  hypermetropia  or  hypermetropic  astig- 
matism. Its  etiology,  and  the  role  which  hypermetro- 
pia plays  in  its  production,  have  been  considered  in  the 
preceding  chapter  (pages  396  and  397),  in  treating  of 
the  ill  consequences  of  that  refractive  fault. 

Donders,  who,  so  far  as  the  anomalies  of  refraction 
are  concerned,  brought  order  out  of  chaos,  was 
the  first  to  recognize  the  intimate  dependence  of 
concomitant  convergent  squint  upon  hypermetropia. 
He,  of  course,  realized  that  hypermetropia  is  a 
far  more  common  condition  than  convergent  squint, 
and  he  explained  this  fact — why  some  hypermetropes 
squint  and  so  many  do  not — in  a  thoroughly  satisfactory 
manner.*  The  desire  for  binocular  vision  and  the 
abhorrence  of  diplopia,  he  tells  us,  suffice  to  prevent  the 
occurrence  of  squint  in  the  great  majority  of  hyperme- 
tropes. Weakness  of  the  internal  recti  muscles  and, 
he  might  have  added,  exceptionally  energetic  accommo- 
dative power,  tend  to  the  same  end.  Among  conditions 
conducing  to  its  occurrence  he  mentions  congenital 
weakness  of  the  external  recti  muscles,  congenital  or 
acquired  difference  in  the  visual  acuteness  or  the  refrac- 
tive condition  of  the  two  eyes,  and  the  exceptionally 
large  value  of  the  angle  alpha  (the  angle  formed  by  the 

*  "The  Anomalies  of  Accommodation  and  Refraction  of  the  Eye," 
pp.  294  et  seq. 


454  PREVALENT    DISEASES    OF    THE     EYE. 

visual  line  and  the  axis  of  the  cornea)  in  hypermetropia. 
And,  again,  he  might  have  added,  inefficient,  or  subnor- 
mal, accommodative  power. 

It  is  evident  why  weakness  of  the  internal  recti  mus- 
cles, and  why  exceptional  power  of  accommodation,  in 
association  with  hypermetropia,  should  render  the  occur- 
rence of  convergent  squint  less  probable;  and  why  insuffi- 
ciency of  the  external  recti  muscles  and  subnormal  ac- 
commodative powder  should  favor  its  development. 
And  since  the  advantages  of,  and  the  desire  to  maintain, 
binocular  vision,  as  well  as  the  annoyances  arising  from 
diplopia,  are  greatly  lessened  by  the  existence  of  a 
marked  difference  in  the  acuteness  of  vision  or  the  re- 
fraction of  the  two  eyes,  it  is  not  difficult  to  comprehend 
why  each  of  these  conditions  should  have  a  like  effect. 
As  to  the  influence  exerted  by  a  large  angle  alpha,  it 
must  be  admitted  that  it  is  not  so  obvious. 

What  has  been  said  as  to  "periodic"  and  "alternat- 
ing" squint  applies  especially  to  the  variety  of  squint 
under  consideration.  There  can  be  little  doubt  that 
most  cases  of  concomitant  convergent  squint,  at  the  out- 
set, are  periodic,  and  the  cases  which  remain  so  per- 
manently are  nearly  always  of  this  type,  and  this  is  true 
also  of  the  majoritv  of  cases  of  alternating  squint. 

Although  so  frequently  found  in  association  with  hv- 
permetropia,  concomitant  convergent  squint  occurs, 
exceptionally,  in  myopia  of  high  grade.  In  these  seem- 
ingly anomalous  cases  there  is,  in  the  first  place,  doubt- 
less a  congenital  lack  of  balance  between  the  external 
and  internal  recti  muscles — the  former  being  insuffi- 
cient and  the  latter  possessing  unusual  strength.  Then, 
it  commonly  happens  that  this  tvpe  of  squint  is  en- 
countered in  myopes  who  have  used  their  eves  a  great 
deal  in  near  vision,  without  correcting  glasses,  holding 


MUSCULAR   ANOMALIES    OF    THE    EYES.  455 

the  printed  page,  for  example,  very  close  to  the  eyes, 
and  reading  with  forced  convergence.  The  effect  of 
this  habitual  overaction  of  the  internal  recti,  and  the 
attendant  stretching  of  the  externi,  is  to  exaggerate  the 
preponderance  of  the  former,  until  finally  there  comes 
a  time  when,  in  regarding  distant  objects,  the  visual  axes 
can  not  be  brought  into  proper  relation,  and  a  con- 
vergent squint,  which  often  continues  to  manifest  itself 
only  in  distant  vision,  is  established. 

Treatment. — In  view  of  the  disfigurement  which  at- 
tends convergent  squint,  and  the  serious  impairment  of 
vision  which  nearly  always  results  in  the  deviating  eye, 
there  seem  to  be  the  best  of  reasons  why  the  defect 
should  be  corrected,  with  as  little  delay  as  possible; 
and,  it  may  be  added,  there  are  few  cases  in  which  this 
can  not  be  done,  provided  the  remedial  measures  indi- 
cated are  employed  as  promptly  as  they  should  be. 

These  measures  consist  in  the  adjustment  of  glasses 
for  the  correction  of  the  usually  present  refractive  fault, 
and  in  operative  procedures  upon  the  ocular  muscles. 
And  here  it  may  be  well  to  state,  parenthetically,  that, 
in  view  of  the  interdependence  of  the  tw^o  conditions,  no 
one  who  is  incapable  of  accurately  determining  and  cor- 
recting refractive  anomalies  is  justified  in  operating  for 
concomitant  squint. 

Only  in  exceptional  instances  can  concomitant  con- 
vergent squint  be  dealt  with  satisfactorily,  without  the 
aid  of  glasses.  Whether  it  can  be  corrected  by  glasses 
alone,  without  operation,  depends  largely  upon  the 
character  and  duration  of  the  squint,  as  wxll  as  upon 
the  degree  of  the  refractive  error  and  the  visual  acute- 
ness  of  the  deviating  eye.  As  a  general  truth,  it 
may  be  said  that  when  a  squint  has  passed  the 
periodic    stage,    and    has  become    firmly    established, 


45^  PREVALENT    DISEASES    OF    THE     EYE. 

it  is  seldom  possible  to  correct  it  without  opera- 
tion. The  cases  likely  to  prove  exceptions  to  this  rule 
are  those  in  which  hypermetropia  of  high  grade  exists, 
with  comparatively  good  central  vision  in  the  deviating 
eye,  such  as  is  usually  found  in  alternating  squint.  On 
the  other  hand,  when  the  squint  is  still  in  the  formative 
stage,  is  still  periodic  in  character,  it  is  always  possible 
to  correct  it  by  glasses  alone;  although,  even  under  such 
circumstances,  an  operation  may  be  indicated  to  im- 
prove the  muscle-balance  and  relieve  asthenopic  symp- 
toms In  every  case  of  squint,  whether  an  operation 
is  to  be  performed  or  not,  a  cycloplegic  should  be  em- 
ployed, and  the  refractive  condition  and  visual  acute- 
ness  of  each  eye  should  be  carefully  determined.  If 
astigmatism  is  present  it,  as  well  as  the  general  refrac- 
tive fault,  must  be  corrected. 

The  ideal  result  aimed  at  in  the  treatment  of  squint 
is  the  re-establishment  of  binocular  vision.  Whether 
this  can  be  accomplished  or  not  depends,  in  great  meas- 
ure, upon  the  character  and  degree  of  the  amblyopia 
in  the  deviating  eye.  In  some  instances,  too,  we  have 
to  contend  with  a  positive  disinclination  to  fuse  images 
formed  in  the  two  eyes  upon  identical  retinal  points. 
As  a  result  of  operation  the  muscle-balance  may  be 
practically  normal,  and  yet  the  squinting  eye  may  show 
no  inclination  whatever  to  "fix"  the  object  which  the 
properly  directed  eye  is  regarding.  The  condition  is 
a  discouraging  one,  and  can  seldom  be  overcome.  Sys- 
tematic exercise  of  the  vision  of  the  eye  which  is  at  fault, 
the  other  being  carefully  excluded,  offers  the  only  hope  of 
accomplishing  this.  If,  on  the  other  hand,  the  sight  of  the 
deviating  eye  is  not  greatly  impaired,  and  an  inclination 
to  binocular  fixation  exists,  the  ideal  result  spoken  of 
can  in  most  instances  be  attained.     In  securing  this 


MUSCULAR    ANOMALIES    OF    THE    EYES.  457 

result  we  are  greatly  aided  often  by  combining  esophoric 
prisms  with  the  lenses  which  correct  the  refractive 
error. 

As  to  the  operative  procedure  best  adapted  to  the  cor- 
rection of  convergent  squint  there  is  not  a  unanimity 
of  opinion.  There  are  those  who  prefer  the  operation 
of  advancement,  though  the  great  majority  of  ophthal- 
mic surgeons  prefer  tenotomy.  My  own  decided  pre- 
ference is  for  tenotomy,  and  I  resort  to  advancement 
only  exceptionally,  and  usually  to  increase  the  effect 
of  a  previously  performed  tenotomy.  The  advantages 
of  tenotomy  are  that  it  is  a  simpler  procedure,  involving 
considerably  less  traumatism  and  much  less  pain  than 
advancement;  that  its  effect  can  be  more  exactly 
gauged;  that,  if  necessary,  it  can  be  repeated  more 
readily;  and  that  it  accomplishes  the  end  in  view,  at 
least,  as  satisfactorily. 

Of  the  several  methods  of  performing  tenotomy  the 
simplest — the  operation  of  Arlt — it  seems  to  me, 
is  decidedly  the  best,  since  it  is  the  easiest  to  execute 
and  the  least  painful,  and  its  effect  can  be  graduated 
with  much  precision.  For  its  performance  there  are 
required  a  speculum  *  (Fig.  i6o),  a  pair  of  straight, 
slightly  blunt-pointed  scissors  (Fig.  i6i),  a  strabismus- 
hook  (Fig.  162),  and  delicate  straight  forceps,  with  teeth 
— two  on  one  blade  and  one  on  the  other — that  project 
but  slightly  (Fig.  163).  If  the  conjunctival  wound  is  to 
be  closed  by  a  stitch,  a  curved  needle  and  a  suitable 

*  This  speculum,  contrived  by  the  late  Dr.  Russell  Murdoch,  of 
Baltimore,  should  be  used  far  more  generally  than  it  is.  Especially 
for  delicate  operations,  such  as  extraction  of  cataract,  it  is,  in  my  opin- 
ion, decidedly  the  best  speculum  that  we  have.  Its  advantages  are 
that  it  is  self-locking,  that  it  exerts  a  minimum  degree  of  pressure  upon 
the  eye,  that  it  can  be  easily  and  quickly  removed  from  between  the 
lids,  and  that  it  affords  an  exceptionally  unobstructed  field  to  the 
operator. 


458 


PREVALENT    DISEASES    OF    THE     EYE. 


needle-holder  (Fig.  164)  should  also  be  provided.     The 
steps  of  the  operation   are  as   follows:  The   speculum 


Fig.  160. — Murdoch's  self-locking  speculum  (about  two-thirds  actual  size). 


Fig.    161. — Strabismus  scissors. 
h 


Fig.  162. — Author's  crochet-pointed  strabismus  hook:  a.  Actual  size  of  hook; 
h,  enlarged  view  of  crochet  point. 


Fig.   163. — Strabismus  forceps. 


having  been  introduced,  the  conjunctiva  just  over  the 
insertion  of  the  tendon  to  be  divided  is  seized  with  the 


MUSCULAR    ANOMALIES    OF    THE    EYES.  459 

forceps,  care  being  exercised  not  to  include  in  their 
grasp  the  underlying  fascia,  and  with  the  scissors  a 
vertical  incision,  somewhat  less  than  i  cm.  in  length, 
is  made  in  the  slightly  elevated  conjunctiva 
(Fig.  165).  The  points  of  the  scissors  are  next 
introduced  through  this  opening,  and  the  conjunc- 
tiva is  rather  widely  separated  from  the  underlying 
fascia.  This  step  is  especially  important  in  oper- 
ating upon  the  rectus  internus,  because,  if  itisdonethor- 
oughly, — the  scissor-points  being  carried  well  toward 
the  inner  canthus — the  unsightly  sinking  of  the  caruncle 


Fig.  164. — Author's  needle-holder. 

SO  often  observed  in  awkwardly  executed  tenotomies 
is  entirely  obviated.  The  exposed  tendon  is  now  seized 
just  back  of  its  attachment,  is  somewhat  elevated,  and 
is  separated  from  the  sclera  by  a  few  snips  of  the  scissors 
(Fig.  166).  If  the  tenotomy  is  intended  to  produce  only 
a  moderate  effect,  the  operation,  except  for  the  closure 
of  the  conjunctival  wound,  may  stop  at  this  point;  but  if, 
as  is  usually  the  case  in  operations  for  squint,  a  more  de- 
cided effect  is  desired,  the  incision,  previously  limited  to 
the  tendon,  must  be  extended,  both  upward  and  down- 
ward, through  Tenon's  capsule.     And  here,  for  the  first 


460 


PREVALENT    DISEASES    OF    THE    EYE. 


time,  to  facilitate  this  last  step  of  the  operation,  it  becomes 
necessary  to  use  the  strabismus-hook.  And  this  is  one 
of  the  chief  advantages  of  Arlt's  operation,  for  the 
manipulations  with  the  hook  are    more  apt   to   cause 


Fig.  165. — Tenotomy  of  the  internal  rectus  of  the  right  eye  by  Arlt's 
method.  The  first  step  of  the  operation — the  conjunctival  incision — com- 
pleted, exposing  the  tendon. 


Fig.    166. — Dissection  of  the  tendon  from  its  scleral  attachment.     (The 
operator  is  standing  behind  the  patient.) 

pain  than  the  actual  cutting  with  the  scissors,  and 
therefore  it  is  desirable  that  it  should  be  employed  as 
little  as  possible. 

The  conjunctival  wound  is  now  brought  together  by 


MUSCULAR    ANOMALIES    OF    THE    EYES. 


461 


means  of  a  single  stitch  of  fine  black  silk  (Fig.  167) — 
except  in  young  children,  because  with  them  the  removal 
of  the  stitch  is  usually  attended  with  considerable  diffi- 
culty— and  a  light  compress  bandage  is  applied  (see  Fig. 
10).  On  the  following  day  the  bandage  is  dispensed 
with,  and  after  three  days  the  stitch  is  removed. 

With  the  eye  thoroughly  under  the  influence  of  cocain, 
and  with  delicacy  of  manipulation,  this  operation  in 
most  instances  is  practically  painless.  In  children, 
simply  because  it  is    impossible    otherwise   to    control 


Fig.    167. — The  operation   completed.     Conjunctival  wound  closed  by   a 
single  black-silk  suture. 


their  movements,  general  anesthesia  is  required;  but 
with  adults  this  is  never  necessary.  Alternating  with 
the  applications  of  cocain,  it  is  advantageous  to  make  a 
few  instillations  of  a  i  :  1000  adrenalin  solution,  as  this 
lessens,  and  sometimes  entirely  obviates,  hemorrhage, 
besides  increasing  the  anesthetic  action  of  the  cocain. 
Since  in  skilful  hands,  and  with  proper  antiseptic 
precautions,  the  operation  may  be  said  also  to  be 
practically  without  risk — infection  being  almost  unheard 
of — there  seems  to  be  no  good  reason  why  it    should 


462  PREVALENT    DISEASES    OF    THE     EYE. 

not  be  resorted  to  whenever  there  is  a  clear  indication 
for  its  performance. 

Should  the  cutting  of  a  single  muscle  leave,  as  it  often 
does,  a  residual  squint,  either  of  two  courses  may  be 
adopted.  The  internal  rectus  of  the  opposite  eye  may 
be  tenotomized  somewhat  less  freely,  or  an  endeavor 
may  be  made  to  overcome  the  residual  defect  by  correct- 
ing the  usually  present  refractive  error  and  combining 
esophoric  prisms  with  the  required  lenses.  The  latter 
course  is  to  be  preferred,  if  the  residual  squint  is  slight 
and  the  refractive  error  of  high  degree;  the  former,  if 
there  is  still  a  decided  squint  left,  and  especially  if  there 
is  not  a  considerable  amount  of  hypermetropia  to  be 
corrected. 

In  former  times,  w^hen  operations  for  squint  were 
done  in  clumsy  fashion, — the  muscle  being  divided  at  a 
considerable  distance  behind  its  point  of  attachment  to 
the  sclera, — and  the  refractive  state  of  the  eyes  was  ig- 
nored, it  frequently  happened  that  the  eye  operated 
upon  "went  the  wrong  way,"  as  it  was  expressed,  a 
scarcely  less  unsightly  divergent  squint  being  substi- 
tuted for  the  previously  existing  convergent  squint.  In 
consequence  of  this  the  operation  fell  into  well-deserved 
disrepute,  which  to  the  present  day  it  has  not  entirely 
outgrown.  It  is  scarcely  necessary  to  point  out  that 
the  modern  operation  is  a  wholly  different  procedure, 
and  that  in  skilful  hands  it  is  attended  by  no  such 
risk. 

It  only  remains  to  add  that  the  earlier  a  convergent 
squint  can  be  corrected  the  better;  since,  other  things 
being  equal,  the  longer  it  is  allowed  to  exist  the  greater 
will  be  the  amblyopia  of  the  squinting  eye.  We  are 
unquestionably  handicapped  in  operating  at  so  early  an 
age  that  the  help  afforded  by  glasses  can  not  be  availed 


MUSCULAR   ANOMALIES    OF    THE    EYES. 


463 


of;   but,  notwithstanding  this  fact,  I  believe  more  is  lost 
than  is  gained  by  postponing  operation. 

Divergent  Concomitant  Squint  or  Strabismus. 
— In  the  preceding  chapter  it  has  been  pointed  out 
that  myopia  plays  almost  as  important  a  role  in  the 
causation  of  divergent  squint  (Fig.  168)  as  hypermetropia 
does  in  that  of  convergent  squint,  and  an  explanation 
of  how  this  occurs  has  been  given.  The  importance  of 
this  influence  is  shown  by  the  fact  that  myopia  exists  in 
about  two-thirds  of  all  cases  of  divergent  squint.  Other 
factors  which  conduce  to  the  development  of  this  variety 
of  strabismus  are  congenital  or  acquired  insufficiency 


Fig.   1 68. — Divergent  strabismus  (Daln,-mple). 


of  the  internal  recti  muscles  and  marked  difference  in 
the  visual  acuteness  of  the  two  eyes. 

When,  from  any  cause,  the  sight  of  one  eye  is 
decidedly  impaired,  so  that  the  advantages  of,  and  the 
disposition  to  maintain,  binocular  vision  are  in  large 
measure  lost,  the  defective  eye  is  prone  to  squint  in 
one  direction  or  another.  It  will  squint  inward,  if  the 
external  recti  muscles  are  relatively  weak,  or  if  the  better 
eye  is  decidedly  hypermetropic.  On  the  other  hand,  if 
there  is  insufficiency  of  the  internal  recti  or  the  better 
eye  is  myopic,  a  divergent  squint  is  very  apt  to  occur. 
Unlike  convergent  squint,    divergent  squint,  which  is 


464  PREVALENT    DISEASES    OF    THE     EYE. 

less  common,  usually  develops  in  adults,  and  is  observed 
I  only  exceptionally  in  children. 

In  myopia  of  considerable  degree,  because  of  the 
nearness  of  the  far-point  of  distinct  vision  and  the 
altered  relation  of  accommodation  and  convergence,  the 
difficulty  of  maintaining  binocular  fixation  is  greatest 
in  near  vision,  as  in  reading,  writing,  etc.  For  this 
reason  it  often  happens  that  the  squint  manifests  itself 
at  first  only  when  near  objects  are  regarded.  Indeed, 
it  is  not  uncommon  for  it  to  continue  to  occur  only  under 
such  circumstances,  binocular  fixation  being  maintained 
in  distant  vision.  At  the  outset  the  squint  is  usually 
periodic,  and  only  after  a  considerable  time  becomes 
constant.  It  is  seldom  alternating,  except  in  the  sense 
that  one  eye  may  be  used  in  distant,  the  other  in  near, 
vision.  In  divergent  concomitant  squint,  probably 
because  the  true  and  false  images  are  usually  so  far 
apart,  there  is  but  little  complaint  of  diplopia,  and  for 
this  reason,  and  because  the  defect  seldom  develops  in 
childhood,  the  regional  amblyopia  characteristic  of 
the  convergently  squinting  eye  is  rarely  observed. 

Treatment. — Only  exceptionally  is  it  possible  to  cor- 
rect a  divergent  squint  without  operation.  The  cases 
in  which  this  may  be  accomplished  are  usually  those  in 
w^hich  a  marked  difference  exists  between  the  refractive 
condition  of  the  two  eves,  or  in  which  the  squint  is  asso- 
ciated with  myopia  of  considerable  degree,  and  occurs 
only  in  near  vision.  In  the  condition  first  mentioned 
the  blurred  image  formed  upon  the  macula  of  the  more 
ametropic  eye  proves  a  source  of  annoyance,  and  the 
squint  may  be  the  expression  of  a  desire  to  get  rid  of  this 
annoyance  rather  than  a  resultof  the  existence  of  decided 
muscular  imbalance.  If,  therefore,  bv  means  of  glasses 
the  vision  of  each  eye  can  be  brought  up  to  about  the 


MUSCULAR    ANOMALIES    OF    THE    EYES.  465 

same  standard,  the  squint  not  infrequently  will  dis- 
appear, and  the  eyes  thereafter  will  work  in  harmony.* 
In  the  cases  associated  with  myopia  of  considerable 
degree,  in  which  the  squint  occurs  only  in  near  vision, 
glasses  that  correct  a  part  of  the  near-sightedness,  by 
removing  the  far-point  of  distinct  vision  to  a  comfortable 
distance  from  the  eyes,  and  by  restoring  more  nearly 
the  normal  relation  between  accommodation  and  con- 
vergence, will  render  binocular  fixation  very  much 
easier,  and  may  cause  the  disappearance  of  the  squint. 

Such  cases,  however,  as  has  been  said,  are  excep- 
tional, and,  as  a  rule,  the  surgeon  may  congratulate 
himself  if,  even  by  the  help  of  an  operation,  he  is  able 
to  correct  a  divergent  squint  so  exactly  as  to  re-establish 
comfortable  binocular  vision.  In  high  degrees  of  my- 
opia  it  is  not  always  best  to  attempt  this,  for  the  progress 
of  the  myopia  is  often  favorably  influenced  by  the 
abandonment  of  binocular  fixation  and  the  convergence 
tension  which  it  implies. 

Divergent  squint  can  not  so  surely  be  corrected 
by  tenotomy  alone  as  can  convergent  squint.  Not 
infrequently  tenotomy  of  the  external  rectus  must 
be  supplemented  by  advancement  of  the  internal  rectus. 
However,  free  tenotomy  of  both  external  recti  muscles, 
not,  as  a  rule,  performed  at  the  same  time,  though  this 
may  be  warrantable,  often  yields  a  very  satisfactory 
result,  even  in  cases  in  which  the  squint  is  pronounced. 
The  procedure  of  Arlt,  already  described,  it  should  be 
stated,  is  as  well  adapted  to  the  correction  of  divergent, 
as  it  is  to  that  of  convergent,  squint.  In  securing  the 
effect  desired  glasses  aff"ord  valuable  assistance,  espe- 
cially in  myopic  cases  and  in  cases  in  which  there  is  ani- 

*  In  the  "Johns  Hopkins  Hospital  Bulletin  "  for  April,  1890,  Vol.  I, 
No.  4,  the  author  has  reported  several  cases  of  this  character. 

30 


466  PREVALENT    DISEASES    OF    THE     EYE. 

sometropia.  With  the  lenses  called  for  by  the  refractive 
fault  exophoric  prisms  may  often  be  combined  with 
advantage. 

When  the  sight  of  the  squinting  eye  is  very  defective, 
a  lessening  of  the  deformity  is  the  most  that  can  be 
hoped  for  from  operation,  since  under  such  circum- 
stances the  restoration  of  binocular  vision  is  not  to  be 
expected.  Even  for  this  purpose,  however,  a  tenotomy 
may  be  justifiable,  since  the  cosmetic  effect  is  often  very 
gratifying. 

Vertical  concomitant  squint  is  rare,  and  is  usu- 
ally the  result  of  a  precedent  paralysis  of  one  of  the 
oblique  muscles,  or  of  one  of  the  superior  or  inferior 
recti  muscles.  It  is  not  uncommon,  however,  in  both 
convergent  and  divergent  squint,  to  find  a  considerable 
amount  of  vertical  deviation  associated  with  the  lateral 
fault. 

Treatment. — Vertical  squint  can  seldom  be  corrected 
without  operation  (tenotomy  of  superior  or  inferior 
rectus),  and  is  more  difiicult  to  deal  with  than  lateral 
squint,  because,  in  the  first  place,  glasses  do  not  afford 
us  the  same  help  in  securing  the  desired  result,  and, 
in  the  next  place,  we  can  depend  upon  the  eyes,  them- 
selves, for  comparatively  little  assistance,  since  they 
are  capable  of  overcoming  but  a  slight  residuum  of 
vertical  squint. 

LATENT  MUSCULAR  ANOMALIES. 

Under  this  head  are  included,  as  has  been  explained, 
all  the  varieties  of  heterophoria,  or,  in  other  words,  all 
the  muscular  anomalies  of  the  eyes,  in  which,  despite  a 
tendency  to  squint,  binocular  vision  is  maintained. 

Although  heterophoric  conditions,  because  less  com- 
mon, are  not  so  frequent  a  cause  of  asthenopia  as  are 
errors  of  refraction,  they  are  quite  as  capable  of  pro- 


MUSCULAR   ANOMALIES    OF   THE    EYES.  467 

ducing  the  manifold  symptoms,  local  and  remote,  which 
we  have  learned  to  attribute  to  eye-strain.  Among  the 
ocular  disturbances  to  which  they  give  rise  may  be  men- 
tioned pain,  intermittent  blurring  of  vision, — attended 
at  times  by  diplopia, — conjunctival  hyperemia,  and 
blepharitis  marginalis;  among  the  more  remote,  head- 
ache, vertigo,  nausea,  neurasthenia,  insomnia,  and 
indigestion.  When  associated  with  ametropia,  they 
may  greatly  aggravate  the  ill  consequences  of  the  refrac- 
tive fault;  but,  to  their  credit  be  it  said,  they  may  exert 
exactly  the  contrary  effect,  as,  for  example,  when  a  not 
too  considerable  exophoria  is  associated  with  hyper- 
metropia,  or  a  not  too  pronounced  esophoria  with  my- 
opia. 

Of  the  several  varieties  of  heterophoria — esophoria, 
exophoria,  and  hyperphoria — the  last  named,  in  which 
there  is  a  tendency  to  vertical  squint,  is  the  one  most 
sure  to  give  rise  to  unpleasant  consequences,  since 
the  eyes  are  less  capable  of  coping  with  it  successfully. 
However,  both  esophoria  and  exophoria  often  cause 
marked  asthenopia,  headache,  etc.,  and  the  latter  con- 
dition, when  associated  with  myopia,  exerts  a  further 
baneful  influence,  since  it  tends  to  promote  the  increase 
of  the  refractive  fault. 

It  has  been  stated  that  a  very  considerable  part  of  the 
latent  muscular  anomalies  of  the  eyes  are  due  to  errors 
of  refraction.  It  is  equally  true  that  a  not  inconsider- 
able part  are  wholly  independent  of  refractive  errors. 
Those  which  belong  to  the  first-mentioned  class  may 
properly  be  termed  appareyit,  those  which  belong  to  the 
latter  class  actual,  muscular  anomalies. 

There  are  extremists  who  contend  that  refractive 
errors  are  responsible  for  all  latent  muscular  anomalies, 
not  of  paralytic  origin.     There  are  other  extremists  who 


468  PREVALENT    DISEASES    OF    THE     EYE. 

hold  exactly  the  opposite  view,  who  belittle  the  influence 
which  errors  of  refraction  exert  upon  muscular  faults, 
and  who  do  not  hesitate  to  tenotomize,  let  us  say,  the 
internal  rectus  for  an  apparent  esophoria,  without  hav- 
ing determined,  with  even  approximate  accuracy,  the 
refractive  condition  of  the  eyes.  The  truth  lies  be- 
tween these  extremes.  It  seems,  indeed,  inexplicable 
that  any  one  who  has  had  experience  in  ophthalmic 
practice,  and  whose  powers  of  observation  are  not  below 
mediocrity,  should,  on  the  one  hand,  deny  the  reality  of 
muscular  insufficiencies,  or,  on  the  other,  fail  to  recog- 
nize the  important  role  which  errors  of  refraction  play 
in  the  causation  of  heterophoria. 

While  it  is  true  that  refractive  errors,  when  present, 
markedly  influence  real  muscular  faults,  there  are  mus- 
cular faults,  as  has  been  said,  which  are  in  no  sense  de- 
pendent upon  ametropia,  and  which  are  just  as  real  as 
ametropia  itself.  Such  faults,  it  may  be  admitted,  are 
not  very  often  met  with  in  emmetropic  eyes;  but  this 
circumstance  finds  its  explanation  in  the  comparative 
rarity  of  emmetropia. 

It  is  not  a  difficult  matter  to  determine  whether  an 
observed  muscular  anomaly  is  actual  or  apparent.  The 
first  step,  of  course,  is  to  ascertain  the  true  refractive 
condition  of  the  eyes,  and  to  do  this  it  is  usually  neces- 
sary to  employ  a  cycloplegic.  If  the  test  fails  to  reveal 
the  existence  of  ametropia,  or  if  it  shows  an  error  of  re- 
fraction incapable  of  producing  the  muscular  anomaly, 
the  reality  of  the  latter  is  demonstrated.  If,  again, 
it  reveals  a  refractive  error  which  might  be  expected  to 
cause  the  muscle-fault,  this  error  must  be  corrected  by 
glasses,  and  the  test  for  muscular  imbalance  repeated. 
Should  these  tests  now  show  a  practically  orthophoric 
condition,  we  may  conclude  that  the  muscular  fault  is 


MUSCULAR    ANOMALIES    OF    THE    EYES. 


469 


not  real,  that  it  is  wholly  the  result  of  the  ametropia. 
Should  they,  on  the  other  hand,  still  show  an  appreciable 
amount  of  heterophoria,  we  are  warranted  in  regarding 
this  residual  fault,  at  least,  as  being  real.  It  should  be 
added  that  the  muscle-balance  tests  just  mentioned 
should  be  made  not  only  while  the  eyes  are  under  the 
influence  of  the  cycloplegic,  but  after  they  have  re- 
covered fully  from  its  effect. 

From  what  has  been  said  as  to  the  significance  of  the 
latent  muscular  anomalies  of  the  eyes,  and  as  to  the  ill 
consequences  to  which  they  give  rise,  it  is  evident  that 
their  determination  and  correction  are  of  prime  impor- 
tance; that,  in  fact,  they  demand 
attention  as  imperatively  as  do 
the  faults  of  refraction. 

As  the  determination  of 
heterophoria  does  not  fall  wiih 
in  the  province  of  the  genei  il 
practitioner,  I  have  not  thought 
it  necessary  to  describe  the 
muscle-balance  tests  to  which 
reference  has  been  made.  I 
may  say,  however,  in  this  con- 
nection, that  I  consider  the  simplest  contrivances 
for  measuring  the  muscle-balance  the  best,  and  that 
I  have  found  no  occasion  to  employ  for  this  purpose 
cumbersome  apparatus,  such,  for  example,  as  the 
phorometer  of  Stevens.  My  chief  reliance,  in  the 
determination  of  hyperphoria,  is  upon  the  multiple 
Maddox  rod  (Fig.  169)  and,  in  the  measurement  of 
esophoria  and  exophoria,  upon  the  modified  vertical 
diplopia  test  of  von  Graefe;  and  in  applying  these  tests 
I  make  use  of  prisms  taken  from  my  trial  case.  The 
muscle-balance  for  near  vision,  I  consider,  should  be 


Fig.  169.— Multiple  Maddox 
rod. 


470 


PREVALENT    DISEASES    OF    THE     EYE. 


determined  with  as  much  care  as  for  distance,  and  in 
doing  this,  especial!}'  in  searching  for  hyperphoria,  I 
have  found  the  "pin-hole"  light  of  Schild,*  used  in 
conjunction  with  the  Maddox  rod,  of  great  assistance 
(Figs.  170  and  171). 


Fig.  170. — Schild's  pin-hole  electric  light. 

The  correction  of  heterophoria  is  to  be  accomplished 
by  glasses  or  by  operative  procedure.  If  the  muscle- 
fault  is  unreal,  if  it  is  dependent  wholly  upon  an  error 
of  refraction,  it  will  disappear  with  the  correction  of  the 

*  Described  in  "The  Ophthalmic  Record"  for  June,  1904,  and 
made  by  Chas.  A.  Euker  &  Co.,  312  N.  Howard  St.,  Baltimore. 


MUSCULAR    ANOMALIES    OF    THE    EYES. 


471 


ametropia.  If  it  is  real,  prismatic  glasses  must  be  pre- 
scribed, or  an  operation  performed — the  former,  if  the 
fault  is  not  marked;  the  latter,  without  hesitation,  if  it 
is  pronounced.  Although  some  ophthalmic  surgeons 
are  skeptical  as  to  the  advisability  of  operating  for  latent 
muscular  anomalies,  my  own  experience  is  that  in  suit- 
able cases  much  can  be  accomplished  by  operation; 
and  here,  as  in  squint,  my  preference  is  for  tenotomy 
of  the  stronger,   rather  than  for  advancement  of  the 


Fig.  171. — Schild's  pin-hole  light  as  employed  in  the  Maddox-rod  test,  at  the 
reading  distance. 

weaker,  muscle,  though  exceptionally  I   deviate  from 
this  rule,  especially  in  cases  of  marked  exophoria. 

Exophoria  (Insufficiency  of  the  Internal  Recti 
Muscles) . — Since  myopia,  as  has  been  pointed  out,  plays 
so  important  a  part  in  the  causation  of  both  apparent 
and  actual  insufficiency  of  the  internal  recti  muscles, 
a  careful  test  of  the  refraction  should  be  made  in  every 
case  of  exophoria.  If  the  test  reveals  a  considerable 
amount  of  myopia,  and  especially  if  the  exophoria  is 


472  PREVALENT    DISEASES    OF    THE     EYE. 

chiefly  noticeable  in  near  vision,  the  muscle-fault  will 
often  prove  to  be  wholly,  or  in  great  part,  unreal.  If,  on 
the  other  hand,  it  reveals  emmetropia,  and  all  the  more 
if  it  shows  hypermetropia  or  hypermetropic  astigmatism, 
the  reality  of  the  muscular  insufficiency  is  proved. 

Treatment. — If  the  exophoria  is  associated  with  my- 
opia, and  is  chiefly  manifest  in  near  vision,  the  partial 
or  complete  correction  of  the  refractive  error  by  glasses 
— the  strength  of  the  glasses  to  be  determined  not  only 
by  the  degree  of  the  myopia,  but  by  the  age  and  accom- 
modative power  of  the  individual  and  the  amount  of  the 
muscular  defect — will  usually  eliminate  the  exophoria, 
or  reduce  it  to  a  facultative  degree.  If  this  is  not  the 
case,  exophoric  prisms  must  be  combined  with  the 
glasses  selected  for  near  vision.  If  the  muscular  fault 
is  present  in  both  distant  and  near  vision,  and,  as  usually 
happens  under  such  circumstances,  is  not  eliminated  by 
the  correction  of  the  myopia,  prisms  for  constant  use 
must  be  prescribed,  or,  if  the  fault  is  of  such  a  degree  as 
to  warrant  it,  a  guarded  tenotomy  of  the  external  rectus 
or  an  advancement  of  the  internal  rectus  must  be  made. 

Exophoria  occurring  independently  of  myopia  is 
susceptible  of  correction  only  by  prisms  or  by  operation. 
If  it  is  not  pronounced,  or  if  it  is  present,  as  sometimes 
happens,  only  in  near,  or  possibly  only  in  distant,  vision, 
the  former  method  is  indicated.  If  it  is  pronounced, 
and  present  in  both  far  and  near  vision,  a  tenotomy  of 
the  external  rectus  of  one  or  both  eyes — a  considerable 
interval,  however,  being  allowed  to  elapse  between  the 
two  operations — should  be  performed,  and  will  com- 
monly prove  markedly  beneficial.  In  extreme  cases, 
as  has  been  intimated,  advancement  of  one  or  both  of 
the  internal  recti  muscles  may  be  combined  with 
tenotomy  of  the  externi. 


MUSCULAR    ANOMALIES    OF    THE     EYES.  473 

Esophoria  (Insufficiency  of  the  External  Recti 
Muscles). — In  the  causation  of  esophoria  hyperme- 
tropia  and  hypermetropic  astigmatism  play  even  a  more 
important  role  than  myopia  does  in  that  of  exophoria, 
and,  since  these  faults  are  so  prevalent,  their  existence 
should  be  suspected  and  sought  for  in  every  case  in 
which  there  is  apparent  weakness  of  the  external  recti 
muscles. 

The  connection  between  hypermetropia  and  eso- 
phoria is  the  same  as  that  between  hypermetropia  and 
convergent  squint.  In  hypermetropia,  as  has  been 
explained,  the  normal  parallelism  between  the  effort  of 
accommodation  and  the  effort  of  convergence  is  de- 
stroyed— accommodation  is  always  in  excess  of  con- 
vergence. Under  such  circumstances  there  is  an  ever- 
present  tendency  to  restore  the  parallelism  between  these 
two  functions.  Convergent  squint  results  when  this 
tendency  is  more  powerful  than  the  desire  to  maintain 
binocular  vision;  esophoria,  when  it  is  less  powerful, 
when  the  desire  for  binocular  vision  prevails.  The 
abandonment  of  the  effort  to  maintain  binocular  vision 
means,  usually,  the  disappearance  of  the  previously 
experienced  asthenopia;  the  maintenance  of  binocular 
vision,  with  the  attendant  esophoria,  means  its  persist- 
ence. The  complete  disappearance  of  the  esophoria, 
as  a  result  of  the  correction  of  the  refractive  error,  proves 
that  the  external  recti  muscles  were  only  seemingly  at 
fault;  its  incomplete  disappearance  shows  an  actual  in- 
sufficiency of  these  muscles.  The  existence  of  a  con- 
siderable amount  of  hypermetropia,  without  esophoria, 
indicates  one  of  three  things — exceptionally  energetic 
accommodative  power,  unusually  strong  external  recti 
muscles,  or  actual  insufficiency  of  the  internal  recti. 

It  must  not  be  supposed,  however,  that  esophoria  is 


474  PREVALENT    DISEASES    OF    THE    EYE. 

always  dependent  upon  hypermetropia.  On  the  con- 
trary, marked  examples  of  this  fault  are  met  with  in 
emmetropes  and  in  individuals  who  are  but  slightly 
hypermetropic,  and  other  cases  are  encountered  in 
which  the  full  correction  of  the  hypermetropia  elimi- 
nates but  a  fraction  of  the  muscle-fault.  These  are  the 
cases  in  which  there  is  actual  insufficiency  of  the  external 
recti  muscles.  Whether,  under  such  circumstances, 
these  muscles  are  imperfectly  developed,  or  are  attached 
to  the  eyeball  in  such  fashion  as  to  lessen  their  efficiency, 
or  whether  they  are  only  relatively  weak  as  compared 
with  their  opponents,  the  internal  recti,  or  whether, 
finally,  the  fault  is  in  their  nervous  supply,  it  is  seldom 
possible  to  determine;  but  there  can  be  little  doubt  that 
every  case  of  real  insufficiency  of  the  external  recti 
muscles  finds  its  explanation  in  the  existence  of  one, 
or,  it  may  be,  more  than  one,  of  these  conditions. 

The  existence  of  esophoria  and  its  degree  are  to  be 
determined  by  the  same  tests  that  have  been  mentioned 
as  best  adapted  to  the  measurement  of  exophoria,  and 
here,  too,  the  muscle-balance  for  near  vision  should  be 
ascertained  with  as  much  care  as  for  distance.  It  goes 
without  saying  that  in  every  case  of  esophoria  a  careful 
test  of  the  refraction  should  be  made,  and  the  eff'ect  upon 
the  muscle-balance  of  the  correction  of  any  refractive 
anomaly  that  may  be  found  noted;  for  only  in  this  way 
can  we  know  whether  we  are  dealing  with  an  actual, 
or  merely  an  apparent,  muscular  fault. 

Treatment. — From  what  has  just  been  said,  it  is  evi- 
dent that  the  first  step  in  the  treatment  of  esophoria 
consists  in  the  determination  of  the  refractive  condition 
of  the  eyes,  and  to  this  end  a  cycloplegic  is  usually  neces- 
sary. If  hypermetropia  or  astigmatism  is  discovered, 
this  must  be  corrected,  and  the  influence  which  this 


MUSCULAR   ANOMALIES    OF    THE    EYES.  475 

correction  exerts  upon  the  muscle-balance  ascertained, 
the  muscle-tests  being  made  not  only  while  the  eyes  are 
under  the  influence  of  the  cycloplegic,  but  after  they 
have  recovered  fully  from  its  effect.  If  a  marked  error  of 
refraction  is  found  to  be  present — a  hypermetropia,  let 
us  say,  of  2  D.  or  3  D.,  and  especially  if  this  is  compli- 
cated by  astigmatism — it  is  commonly  best  to  be  satis- 
fied, for  the  time  being,  with  a  fairly  full  correction  of 
this  defect,  even  though  this  may  leave  a  considerable 
residuum  of  esophoria;  for,  with  the  disappearance  of 
the  asthenopia  and  the  tension  of  accommodation,  it  is 
not  unusual  to  find  a  decided  improvement  in  the  mus- 
cle-balance. If,  however,  in  spite  of  such  correction, 
the  asthenopia  persists,  and  the  residual  esophoria  does 
not  diminish,  one  of  two  things  must  be  done — either 
prisms  must  be  combined  with  the  previously  prescribed 
lenses,  or  a  tenotomy  must  be  performed. 

No  hard  and  fast  rule  can  be  laid  down  as  to  when  one 
and  when  the  other  of  these  measures  should  be  resorted 
to;  but,  in  general,  it  may  be  said  that  when  more  than 
6°  of  esophoria  in  distant  vision,  and  its  equivalent,  2° 
or  3°,  in  near  vision,  remain  after  the  correction  of  the 
refractive  error,  or  when  the  asthenopic  symptoms  per- 
sist notwithstanding  the  correction  of  4°  of  esophoria 
by  prisms,  a  tenotomy  is  indicated.  This  same  rule  as 
to  the  choice  between  prisms  or  a  tenotomy,  it  may  be 
added,  holds  good  when  no,  or  only  a  trivial,  error  of 
refraction  exists. 

It  should  be  borne  in  mind,  however,  that  the  ocular 
muscle-balance  is  often  markedly  influenced  by  the 
general  condition  of  the  individual,  and  that  a  pro- 
nounced change  for  the  better  in  this  respect  may 
follow  temporary  rest  of  the  eyes,  and  a  building  up  of 
the  system  by  suitable  tonics.     One    should    hesitate. 


4/6  PREVALENT    DISEASES    OF    THE    EYE. 

therefore,  to  resort  to  operation  if  there  are  reasonable 
grounds  for  supposing  that  the  symptoms  are  but  the 
expression  of  a  run-down  state  of  the  system,  of  a  gen- 
eral lack  of  muscular  tone.  When,  as  not  infrequently 
happens,  the  muscle-balance  is  at  fault  in  distant  vision 
only,  or,  it  may  be,  in  near  vision  only,  a  tenotomy  is 
contraindicated,  since  it  must  necessarily  do  as  much 
harm  as  good,  substituting  for  one  sort  of  heterophoria 
another  sort,  quite  as  apt  to  give  rise  to  annoying  symp- 
toms. 

As  to  the  advisability  of  operating  at  all  for  latent 
muscular  anomalies  there  is  still,  as  has  already  been 
mentioned,  considerable  diversity  of  opinion.  My  own 
convictions  upon  this  point  are  very  definite.  Con- 
servatism is  to  be  commended,  and  an  operation  is  not 
to  be  thought  of  until  the  influence  of  the  refraction 
upon  the  muscle-balance  has  been  carefully  studied. 
When,  however,  this  source  of  error  has  been  eliminated, 
and  there  are  clear  indications,  as  I  view  them,  for  a 
tenotomy,  I  operate  with  the  fullest  confidence  that 
marked  benefit  will  result.  When,  some  years  ago,  I 
first  began  to  tenotomize  non-squinting  eyes,  I  confess 
I  did  so  with  some  trepidation;  but  abundant  experience 
has  convinced  me  that  few  surgical  procedures  yield 
more  gratifying  results  than  a  clearly  indicated  tenotomy 
for  the  relief  of  muscular  asthenopia. 

Perhaps,  I  should  make  it  plain  that  by  "tenotomy" 
I  mean  a  real  division  of  the  tendon.  There  is,  in  my 
opinion,  no  room  for  the  so-called  graduated  or  partial 
tenotomies.  If  the  muscle-fault  is  so  trivial  that  it  can 
be  relieved  by  such  a  procedure,  it  is  too  trivial  to  re- 
quire operation  at  all;  it  can  be  more  satisfactorily  dealt 
with  by  means  of  glasses.  On  the  other  hand,  if  it  is 
sufficiently  pronounced  to  demand  operation,   it  will 


MUSCULAR    ANOMALIES    OF    THE    EYES.  477 

certainly  not  be  relieved  by  a  procedure  which  is  Httle 
better  than  a  pretence.  A  "guarded  tenotomy,"  that 
is  to  say,  one  in  which  the  tendon  is  completely  divided, 
but  the  section  is  not  extended  to  Tenon's  capsule,  is 
frequently  indicated;  but  an  operation  which  accom- 
plishes less  than  this  had  better  be  left  undone. 

It  has  been  a  matter  of  surprise  to  me  how  much 
tendon-cutting  is  not  only  permissible,  but  is  demanded, 
in  certain  cases  of  lateral  heterophoria.  Not  very 
infrequently  in  marked  esophoria  a  free  tenotomy 
of  both  internal  recti  muscles,  and  in  pronounced  exo- 
phoria  an  equally  free  division  of  both  external  recti 
muscles,  will  hardly  suffice  to  restore  a  normal  muscle- 
balance,  although  a  squint  has  never  manifested  itself. 
It  is  noteworthy  that  an  actual  squint  is  often  corrected 
by  less  free  tenotomizing  than  is  sometimes  demanded 
in  these  latent  muscular  faults. 

Hyperphoria, — This  condition,  in  which  there  is  a 
supptessed  inclination  to  vertical  squint,  is  one  of  the 
most  annoying  of  the  latent  muscular  faults.  From 
exophoria  and  esophoria  it  differs  essentially  in  that  it 
is  but  little  influenced  by  the  refractive  condition  of  the 
eyes — anisometropia,  in  which  the  eyes  are  of  unequal 
focus,  being  the  only  ametropic  condition  which  seems 
to  promote  its  development.  More  constantly,  there- 
fore, than  the  lateral  forms  of  heterophoria  it  is  dis- 
tinctly a  muscular  fault.  Not  infrequently,  it  would 
seem,  it  is  the  result  of  an  incompletely-recovered-from 
paralysis  of  one  of  the  muscles  which  have  to  do  w^th 
the  vertical  movements  of  the  eyes.  In  other  cases  it  is 
due  to  some  congenital  or  acquired  insufficiency  of  one 
of  these  same  muscles. 

Hyperphoria  is  capable  of  producing  any  and  all  of 
the  distressing  symptoms,  local  and  remote,  which  have 


47^  PREVALENT    DISEASES    OF    THE    EYE. 

been  described  as  arising  from  eye-strain,  and,  although 
it  is  not  a  common  defect,  it  should  be  looked  for  in 
every  case  of  asthenopia.  Exceptionally  it  is  present 
only  in  near,  or  it  may  be  only  in  distant,  vision;  it 
should  be  sought  for,  therefore,  in  both.  The  best  test 
which  has  been  devised  for  its  detection  and  measure- 
ment is  the  multiple  rod  of  Maddox,  supplemented  in 
the  tests  for  near  vision,  as  has  already  been  mentioned, 
by  the  pin-hole  light  of  Schild. 

Treatf72ent.— Hyperphoria,  may  be  corrected  by 
prisms  or  by  operation.  If  the  defect  is  pronounced, 
a  guarded  tenotomy  should  be  performed.  If  it  is  not 
pronounced,  it  is  much  better  to  correct  it  by  means  of 
prisms.  Experience  has  taught  me  that  it  is  more 
difficult  to  predicate  the  effect  of  a  tenotomy  upon  a 
superior  or  an  inferior  rectus  muscle  than  of  one  upon 
either  of  the  lateral  recti.  I  am,  therefore,  little  dis- 
posed to  operate,  as  some  surgeons  do,  for  the  correction 
of  the  lower  degrees  of  vertical  heterophoria.  Such 
cases,  that  is  to  say,  cases  in  which  there  are  not  more 
than  3°  or  4°  of  hyperphoria,  can  almost  always  be 
dealt  with  satisfactorily  by  means  of  vertical  prisms, 
either  alone  or  in  combination  with  such  other  correc- 
tion as  may  be  demanded.  And  even  in  the  higher 
grades  the  tenotomy  should  be  distinctly  "guarded"; 
for  it  is  better  to  accomplish  too  little — and  later,  per- 
haps, operate  upon  the  other  eye — than  to  do  too  much. 

In  operations  upon  the  lateral  muscles  glasses  usually 
afford  us  much  assistance,  and,  besides,  these  muscles 
are  more  fully  under  the  control  of  the  will,  so  that  a 
slight  over-correction  or  under-correction  is  not  a  matter 
of  moment,  since  the  eyes  come  to  our  assistance,  so  to 
speak,  and  help  us  greatly  in  securing  the  result  desired. 
In  operations  upon  the  vertical  muscles  this  is  not  the 


MUSCULAR    ANOMALIES    OF    THE    EYES.  479 

case,  and  a  slight  over-correction  will  sometimes  give 
quite  as  much  discomfort  as  the  original  defect. 

Again,  it  is  not  always  possible  to  secure  a  result 
which  is  equally  satisfactory  in  both  far  and  near  vision. 
If  the  superior  rectus  of  the  upward-tending  eye  be 
divided,  just  the  effect  desired  in  near  vision  may  be 
obtained,  but  when  the  eyes  are  directed  to  distant 
objects  there  may  be  trouble.  On  the  other  hand,  if 
the  inferior  rectus  of  the  opposite  eye  be  severed,  all 
may  be  well  in  distant  vision,  but  not  in  near  vision.  In 
a  word,  more  caution  is  requisite,  and  less  assurance  as 
to  the  outcome  can  be  felt,  in  operating  for  the  correc- 
tion of  vertical,  than  for  the  correction  of  lateral, 
heterophoria.*  At  the  same  time,  there  are,  unquestion- 
ably, cases  in  which  an  operation  is  clearly  demanded, 
and  in  which  relief  can  be  obtained  in  no  other  way. 

*  In  a  paper,  "Are  tenotomies  for  hyperphoria  necessarily  more 
uncertain  in  their  results  than  those  for  esophoria  and  exophoria," 
pubhshed  in  the  "Trans,  of  the  American  Ophthalmological  Society" 
for  1903,  and  in  the  "Maryland  Medical  Journal,"  Jan.,  1904,  the 
author's  views  upon  this  point  have  been  more  fully  set  forth,  and 
illustrative  cases  reported. 


CHAPTER  XIII. 

INJURIES  OF  THE  EYE  AND  ITS  APPENDAGES. 

Injuries  of  the  eyelids,  of  moment,  are  not  of 
common  occurrence,  and,  therefore,  the  subject  does 
not  demand  extended  consideration.  A  chief  aim  in 
dealing  with  traumatic  lesions  of  the  hds  is  to  prevent 
subsequent    deformity,    especially    malposition    of  the 


Fig.  172. — Great  deformity  of  the  lid  from  a  knife  wound — the  deformity 
being  in  large  measure  due  to  lack  of  early  surgical  attention  (Lawson). 

lid-margins  and  of  the  lacrimal  puncta,  since  this  is 
not  only  attended  by  considerable  facial  disfigurement, 
but  is  apt  to  give  rise  to  troublesome  epiphora  (Fig.  1 72). 
The  occurrence  of  anchyloblepharon  (adhesion  of  the 
lid-margins)  (Fig.  173)  and  of  symblepharon  (adhesion 
of  the  lid  to  the  eyeball)  is  also  to  be  carefully  guarded 
against.     As  the  tissues  of  the  lids  are  very  vascular, 

480 


.INJURIES    OF    THE    EYE    AND    APPENDAGES.         48 1 

sloughing  is  not  apt  to  occur,  and  stitches  may  be  used 
freely  to  secure  accurate  apposition. 


■a^^'^fci^ 


Fig.  173. — Symblepharon  and  anchyloblepharon  following  burn  by  molten 
iron  (Haab). 


'"^^^^fffii!^' 


Fig.   174. — Symblepharon  following  lime  burn  (Hansell  and  Sweet). 

Burns  of  the  external  surface  of  the  lids  are  often 
difficult  to  deal  with,  and,  if  severe,  are  prone  to  produce 
ectropion.     Burns  of   their  conjunctival  surface   from 

31 


482  PREVALENT    DISEASES    OF    THE     EYE. 

caustic  agents,  molten  metal,  etc.,  tend  to  the  produc- 
tion of  entropion  and  symblepharon  (Fig.  174). 

Treatment. — Incised  wounds  of  the  lids  (Fig.  175), 
after  having  been  thoroughly  cleansed  with  a  i  :  5000 
sublimate  solution,  should  be  neatly  closed  by  a  liberal 
use  of  stitches  (fine  black  silk),  and  dressed  with  silver- 
foil  and  collodion.  Lacerated  wounds  commonly  do 
better  with  a  wet  dressing — a  gauze  pad,  wet  with  a  sat- 
urated solution  of  boracic  acid,  and  kept  in  place  with  a 
light  bandage.  The  presence  of  any  foreign  substance  in 
the  wound  should  be  carefully  searched  for.  Loss  of  a 
considerable  part  of  the  external  integument  of  the  lid 


Fig.  175. — Incised  wound  of  the  palpebral  margin  (Lawson). 

must  be  replaced  by  skin  grafts,  the  thin  grafts  of 
Thiersch  being  best  adapted  for  this  purpose.  Slitting 
of  the  canaliculus,  the  lower  one  especially,  is  at  times 
indicated  for  the  relief  of  epiphora  consequent  upon 
wounds  of  the  lids. 

Burns  of  the  external  surface  of  the  lids  should  be 
anointed  with  borated  vaselin,  to  which  cocain  may  be 
added,  or  thev  may  be  covered  with  absorbent  gauze 
wet  with  a  solution  of  sodium  bicarbonate.  Carbolized 
oil  and  lime-water  is  also  a  useful  application.  In 
burns  of  the  palpebral  or  bulbar  conjunctiva  a  solution 
of  atropin  (alkaloid)  in   castor-oil  (gr.  iv-3j)  is  useful. 


INJURIES    OF    THE    EYE    AND    APPENDAGES.        483 

Gunpowder  burns  are  especially  annoying  from  the 
disfigurement  which  they  cause.  EflForts  to  remove 
mechanically  the  disintegrated  powder-grains  are  usu- 
ally unsuccessful.  If,  however,  these  efforts  are  sup- 
plemented by  the  application  of  hydrogen  peroxid  to 
the  stained  tissue  better  results  are  obtained.  The 
application  is  conveniently  made  by  means  of  a  sharp 
toothpick,  armed  with  a  little  absorbent  cotton. 

Destruction  of  the  external  integument  of  the  lids 
resulting  from  burns  may  call  for  Thiersch  grafts,  which 
are  best  applied  after  the  burned  surface  has  become 
covered  with  granulations.  When  the  burn  has  in- 
volved  the  lid-margins  or  the  palpebral  and  bulbar 
conjunctiva,  the  occurrence  of  anchyloblepharon  and 
symblepharon  should  be  guarded  against  by  repeated 
separation  of  the  opposed  raw  surfaces  and  the  liberal 
application  of  vaselin. 

Injuries  of  the  Bulbar  Conjunctiva. — Considerable 
wounds  of  the  bulbar  conjunctiva,  without  involvement 
of  the  deeper  tunics  of  the  eye,  are  rare.  Occasionally, 
however,  the  conjunctiva  may  be  so  lacerated  as  to  re- 
quire the  careful  insertion  of  stitches,  a  procedure 
fraught  with  little  or  no  risk. 

Severe  burns  of  the  conjunctiva,  from  "concentrated 
lye,"  lime,  strong  acids,  and  molten  metal  (Fig.  176),  are 
more  common,  and,  as  they  often  involve  the  cornea, 
and  are  apt,  as  has  been  pointed  out,  to  cause  symble- 
pharon, they  are  of  serious  concern. 

Treatment. — In  burns  of  the  conjunctiva,  if  the  fornix 
has  escaped  injury,  it  is  usually  possible,  through  the 
measures  described  in  treating  of  injuries  of  the  lids,  to 
prevent  the  occurrence  of  symblepharon;  but  when  this, 
as  well  as  the  tarsal  and  bulbar  conjunctiva,  is  involved, 
our  efforts  in  this  direction  are  almost  sure  to  prove  un- 
availins:. 


484 


PREVALENT    DISEASES    OF    THE     EYE. 


When  the  burn  has  been  caused  by  a  caustic  sub- 
stance, such  as  lye,  lime,  or  a  strong  acid,  and  the  case 
is  seen  promptly,  the  eye  should  be  bathed  freely  with  a 
chemically  neutralizing  agent,  such  as  diluted  vinegar, 
if  the  burn  has  been  produced  by  lime  or  lye,  or  a  solu- 
tion of  sodium  bicarbonate,  if  it  is  the  result  of  an  acid. 
Any  remnants  of  the  caustic  substance  should,  of  course, 
be  carefully  removed.     The  subsequent  treatment  con- 


Fig.   176. — Recent  burn  of    the  palpebral    and   ocular  conjunctiva    by  a 
piece  of  hot  iron  (Haab). 

sists  in  douching  the  eye  with  a  fifteen-grain  solution  of 
boracic  acid,  in  the  instillation  of  a  four-grain  solution 
of  atropin  (alkaloid)  in  castor-oil,  and  in  efforts  to  pre- 
vent, as  has  been  explained,  the  formation  of  adhesions 
between  the  lids  and  the  eyeball. 

In  incised  or  lacerated  wounds  of  the  conjunctiva, 
after  the  parts,  if  they  are  not  disposed  to  fall  together, 


INJURIES    OF    THE     EYE    AND    APPENDAGES.        485 

have  been  united  by  stitches,  a  collyrium  of  boracic  acid 
should  be  prescribed,  and,  if  there  is  much  discomfort 
and  tumefaction,  a  lotion  of  opium  and  boracic  acid, 
to  be  applied  over  the  lids  on  absorbent  gauze. 

Superficial  Injuries  of  the  Cornea. — Burns  of  the 
cornea  are  of  serious  concern  because,  when  at  all  severe, 
they  are  apt  to  leave  a  persistent  opacity,  which,  if  cen- 
tral, will  greatly  impair  vision  (Fig.  177).  One  of  the 
most  unfortunate  cases  of  this  kind  that  I  have  en- 
countered resulted  from  dropping  aqua  ammoniae  into 
the  eye  in  mistake  for  a  collyrium.  A  severe  and 
obstinate  keratitis  follow^ed,  and  an  opacity  was  left 
which  markedly  and  permanently  impaired  the  sight. 


Fig.  177. — Leucoma  resulting  from  a  lime  burn  (Lawson). 

Non-penetrating  w^ounds  of  the  cornea  are  seldom 
attended  by  untoward  results,  unless  they  happen  to  be- 
come infected,  or  involve  the  visual  zone  and  give  rise 
to  persistent  opacity.  Abrasions,  which  simply  dis- 
turb the  corneal  epithelium,  though  they  may  cause 
acute  suffering  for  a  short  time,  soon  heal,  as  the  epi- 
thelium is  quickly  regenerated. 

Treatment. — If  there  is  not  much  discomfort,  and  the 
wound  is  not  infected,  no  other  treatment  than  the  in- 
stillation of  a  ten-grain  solution  of  boracic  acid  is  called 
for.  If  there  is  considerable  irritation,  photophoria, 
and   lacrimation,   atropin   (one  to  four  grains  to  the 


486  PREVALENT    DISEASES    OF    THE     EYE. 

ounce)  should  be  added  to  the  boracic  acid  solution. 
A  one-  to  two-grain  solution  of  the  local  anesthetic 
holocain  hydrochlorate  is  also  a  useful  application,  as  it 
affords  prompt  relief  from  pain,  is  measurably  antisep- 
tic, and  does  not  disturb  the  corneal  epithelium  and 
thereby  favor  infection,  as  does  cocain,  which  is  much 
oftener  employed  in  like  circumstances. 

If  it  is  evident  from  the  presence  of  pus  in  the  wound 
and  in  the  neighboring  corneal  tissue  that  infection  has 
occurred,  the  wound  should  be  cleaned,  and  carefully 
cauterized  with  pure  carbolic  acid.  The  cleaning  and 
the  application  of  the  acid  can  be  done  effectually  and 
conveniently  by  means  of  a  sharp,  wooden  toothpick, 
about  the  tip  of  which  a  very  little  absorbent  cotton  has 
been  tightly  wound.  The  acid  should  be  used  in 
minute  quantity,  and  should  not  be  permitted  to  come 
in  contact  with  the  uninjured  corneal  surface.  After- 
ward the  eye  should  be  flushed  with  a  boracic  acid  or 
normal  salt  solution.  Further  treatment  should  consist 
in  dropping  freely  into  the  eye,  as  often  as  once  in  three 
hours,  freshly  prepared,  undiluted  chlorin  water,  which 
is  one  of  the  most  efficient,  and  at  the  same  time  one  of 
the  best  borne,  ocular  antiseptics.  In  addition,  atropin 
or  holocain  should  be  prescribed,  and,  if  there  is  much 
pain,  an  opium  lotion.  Should  the  wound  after  twentv- 
four  hours  still  present  an  unhealthy  appearance,  it 
should  be  cleaned,  and  the  carbolic  acid  again  applied. 
In  burns  of  the  cornea  the  solution  of  atropin  in  castor- 
oil,  already  mentioned,  is  an  excellent  application. 

The  Superficial   Lodgment  of   Foreign  Bodies 

in  the  Eye. — This  is  one  of  the  commonest  accidents 
to  which  the  eye  is  subject,  and,  though  seldom  followed 
by  serious  consequences,  it  often  gives  rise  to  much 
suffering,  which  can  be  immediately  relieved  bv  the 


INJURIES    OF    THE    EYE    AND    APPENDAGES.        487 

exercise  of  a  little  dexterity  upon  the  part  of  the  physi- 
cian whose  help  may  be  sought.  On  the  other  hand, 
the  display  of  a  considerable  measure  of  sinisterity  on 
his  part  (if  the  word  is  permissible)  is  not  apt  to  be  soon 
forgotten  by  the  unfortunate  patient. 

Mechanics,  particularly  those  engaged  in  metal- 
grinding  and  polishing,  stone-cutting,  and  similar  occu- 
pations, are  especially  subject  to  this  accident,  and  so 
are  persons  who  are  much  exposed  to  wind  and  dust  and 
to  flying  cinders. 

Almost  without  exception,  foreign  bodies  which  do 
not  penetrate  the  globe  find  lodgment — if  they  find  it  at 
all,  for  many  are  washed  out  by  the  tears  or  removed  by 
the  individual's  own  elForts — in 
one  of  two  places:  either  they 
attach  themselves  to  the  cornea, 
or  they  adhere  to  the  inner  sur- 
face of  the  upper  lid,  that  is  to  JJ^'  ^78.-Foreign  body 
'  '  _  _  adherent    to   inner   surface 

say,      to      the      tarsal      conjunctiva    of  upper  lid.     Lid  everted 

(Fig.    178),   for   they    rarely   find  ^^    ^how   a    usual   point 

,      .  .  ,  .  of  lodgment  (Jackson). 

their  way  mto  the  superior  retro- 

tarsal  fold.  In  the  exceptional  instances  in  which  a 
foreign  body  adheres  to  the  bulbar  conjunctiva,  it  will 
be  found  that  it  has  hit  the  eye  with  considerable  force, 
or  was  hot  at  the  moment  of  impact,  and  has  partly 
or  completely  penetrated  this  membrane. 

The  cornea  is  the  usual  place  of  lodgment  for  foreign 
bodies  which  are  driven,  so  to  speak,  into  the  eye,  and 
for  this  reason  it  is  there  they  are  commonly  discovered 
in  the  case  of  metal-grinders,  stone-cutters,  etc.  In- 
deed, it  is  not  unusual  to  find  the  corneae  of  persons 
engaged  in  such  occupations  studded  over  with  innu- 
merable little  nebulous  opacities,  each  marking  the 
point  of  impact  of  a  bit  of  steel  or  stone,  or  a  particle  of 


488  PREVALENT    DISEASES    OF    THE    EYE. 

emery.  Cinders,  and  such  like  substances,  which  sim- 
ply "fly  into  the  eye,"  have  no  such  definite  predilec- 
tions, and  attach  themselves  as  often  to  the  superior 
tarsal  conjunctiva  as  to  the  cornea. 

The  canaliculus  is  one  of  the  unusual  places  in  which 
foreign  bodies  are  found,  and  yet  they  sometimes  lodge 
there,  especially  detached  evelashes,  which  commonly 
enter  but  for  part  of  their  length,  the  projecting  portion 
causing  much  discomfort  by  coming  in  contact  with 
the  sensitive  bulbar  conjunctiva. 

There   is   a   class  of  foreign  bodies,  met   with  from 

time  to  time,  that   seem  to  deserve  especial   mention, 

because  their  true  character  is  apt  to  be  overlooked  by 

the  inexperienced,  and  because,  when  once  they  have 

,  attached  themselves  to  the  eye, 

they  have  a  habit  of  remaining 

attached   for  an  almost  interm- 

>7    i^,7^~~i^'<^  inable  period.     I  have  preserved 

L     _       '  quite  an  interesting  collection  of 

Fig. 1 79.— "Chaff-particle"  these  intractable  little  intruders, 

attached  to  the  corneal  limbus  ^^.j^j^j^  ^^^^3^^^  ^f  ^  portion  of  the 
(Haab).  ' 

outer  shell  of  some  tiny  seed — 
weed  or  grass  seed  (Fig.  179).  They  have  several 
peculiarities,  which  explain  their  unusual  behavior: 
They  are  concavo-convex  in  shape,  they  are  semi- 
transparent,  and  they  are  capable  of  resisting  for  a 
very  long  time  the  solvent  action  of  the  secretions  of 
the  eye.  Their  shape  makes  them  adhere  firmly  to 
the  eye, — they  are  almost  always  found  upon  the 
cornea, — their  indestructibility  renders  them  very 
nearly  everlasting,  and  their  transparency  causes 
their  true  character  to  be  easily  overlooked.  In  my 
collection  there  is  one  of  these  shells  which  remained 
attached  to  the  cornea  for  twelve  months,  and  there  are 


INJURIES    OF    THE    EYE    AND    APPENDAGES.        489 

several  which  maintained  their  hold  for  from  two  to  five 
months;  and  I  may  add,  in  support  of  what  I  have 
said  as  to  the  possibility  of  a  mistaken  diagnosis  being 
made  in  these  cases,  that  one  of  my  earlier  patients,  with 
this  sort  of  foreign  body,  narrowly  escaped  an  energetic 
course  of  mercury  at  the  hands  of  his  family  physician. 

The  suffering  caused  by  the  presence  of  a  foreign 
body  in  the  eye  varies  greatly  in  different  individuals; 
but  usually  it  is  severe,  and  most  intense  when  the  body 
is  sharp  or  rough,  and  is  attached  to  the  tarsal  con- 
junctiva in  such  a  position  as  to  cause  it,  from  the  move- 
ments of  the  eye  and  lids,  to  scrape  the  surface  of  the 
cornea.  Under  such  circumstances  the  upper  part  of 
the  cornea  is  sometimes  found  extensively  denuded  of 
its  epithelium. 

In  reaching  a  diagnosis  as  to  the  presence  of  a  foreign 
body  in  the  eye,  it  is  well  to  bear  in  mind,  in  the  first 
place,  that  a  foreign  body  frequently  enters  the  eye  with- 
out the  knowledge  of  the  individual  or  any  suspicion  on 
his  part  that  such  an  accident  has  occurred,  and,  in  the 
next  place,  that  patients  often  insist  that  a  foreign  body 
is  present,  when  such  is  not  the  case.  Whatever  the 
patient's  convictions,  it  is  always  best,  in  every  case  in 
which  the  symptoms  even  remotely  suggest  the  pro- 
priety of  so  doing,  to  search  carefully  for  the  possible 
presence  of  some  irritating  foreign  substance.  The 
cornea  should  first  be  inspected, — and  here  "oblique 
illumination"  (see  page  19)  will  often  prove  of  in- 
valuable assistance — and  then  the  upper  lid  should  be 
everted,  as  described  on  page  22,  and  the  tarsal  con- 
junctiva carefully  scanned.  If  a  foreign  body  is  not 
found  in  either  of  these  places,  and  is  not,  as  may  pos- 
sibly happen,  lying  loose  upon  the  bulbar  conjunctiva 
or  in  the  lower  retrotarsal  fold,  it  may  safely  be  con- 
cluded that  none  is  present. 


490  PREVALENT    DISEASES    OF    THE     EYE. 

Treatment. — In  general,  whether  a  foreign  body  be 
lodged  upon  the  cornea  or  beneath  the  upper  Hd,  it  can 
be  most  easily  removed — simplv  wiped  from  its  point 
of  attachment — by  the  help  of  a  sharp,  wooden  tooth- 
pick, with  a  little  absorbent  cotton  wrapped,  mop- 
like, over  its  point  (Fig.  i8o).  This  will  not  suffice, 
however,  if  the  foreign  bodv  has  been  driven   forcibly 


Fig.  1 80. — Toothpick  armed  with  cotton  for  removal  of  foreign  bodies. 

into  the  eve,  and  is  embedded  in  the  corneal  tissue. 
Under  such  circumstances  an  old-fashioned  couching 
needle,  or  a  similar  needle  such  as  is  made  now- 
adays expresslv  for  this  purpose  (Fig.  181),  should  be 
employed,  as  the  foreign  body  must  be  picked  out  of 
its  bed.  To  prevent  possible  infection  the  needle 
should,  of  course,  be  previously  sterilized  by  immersion 
in  boiling;  water. 

In  removing  a  foreign  body  from 
the  cornea  it  is  always  best  to  employ 
cocain,  which  tends  to  loosen  its  hold, 
besides  rendering  the  operation  pain- 
less   and,  therefore,   much    easier  of 

Fig.   181.  — Xeedle  ^  ,-r^,  . 

r  ^   (  f     ■      performance.       I  his  is  not  necessarv, 

for  removal  of  foreign    r  .  ' 

bodies    embedded  in  however,  when  the  bod\'  is  attached 
the  cornea.  ^^  ^j^^  inner  surface  of  the  lid,  as  then 

its  removal  is  a  painless  procedure. 

After  the  removal  of  a  scale  of  iron  or  steel,  or  a  bit 
of  emer}',  from  the  cornea  it  often  happens  that  a  brown- 
ish stain  is  left,  which  conveys  the  impression  that  the 
removal  has  not  been  complete.  Further  efforts,  at  the 
moment,  to  detach  this  are  apt  to  prove  abortive,  and 
considerable  traumatism  may  result  if  these  efforts  are 


PLATE  X. 


^ 


Rupture    of    the    Sclera,    with    Hemorrhage    ixto    the    Anterior 

Chamber   (after  Sichel). 


INJURIES    OF    THE    EYE    AND    APPENDAGES.        49I 

persisted  in.  It  is  better  to  wait  for  twenty-four  or 
forty-eight  hours,  when  it  will  be  found  that  the  seeming 
remnant  of  the  foreign  body,  which  is,  in  fact,  only 
stained  cornea  tissue,  has  become  loosened,  and  can  be 
easily  removed. 

If  keratitis  has  resulted  from  the  irritation  produced 
by  a  foreign  body,  or  if  infection  of  the  wound  has  oc- 
curred, the  measures  prescribed  for  the  treatment  of 
simple  or  infected  wounds  of  the  cornea,  as  may  be  indi- 
cated, should  be  promptly  employed. 

The  extraction  of  a  foreign  body  which  is  deeply 
embedded  in  the  cornea,  and  which  may  easily  be  dis- 
placed into  the  anterior  chamber,  is  a  delicate  proce- 
dure, which  had  best  be  left  to  expert  hands. 

Contusions  of  the  eye  are  of  common  occurrence, 
but  fortunately,  owing  to  the  protection  afforded  by  the 
bony  orbital  margin  and  the  elastic  cushion  of  fat  which 
occupies  the  depth  of  the  orbit  and  permits  of  consider- 
able recession  of  the  eyeball,  serious  injury  seldom  re- 
sults, only,  indeed,  when  the  blow  is  exceptionally  severe 
or  is  of  unusual  character.  But  for  these  provisions 
of  nature,  many  eyes  only  "blacked"  by  blows  would, 
doubtless,  be  irreparably  damaged. 

Blows  from  objects  of  such  shape  or  size  as  not  to  be 
arrested  by  the  orbital  margin  are  the  ones  which  are 
apt  to  be  disastrous.  Rupture  of  the  eyeball  (see 
Plate  X),  dislocation  of  the  lens,  laceration  of  the 
iris  (Fig.  182),  iridodialysis  (Fig.  183),  detachment  or 
other  injury  of  the  retina  and  choroid  coat,  and  exten- 
sive intraocular  hemorrhage,  are  among  the  conse- 
quences of  such  injuries.  On  the  other  hand,  even 
severe  blows  from  larger  objects,  such  as  the  fist,  are 
seldom  followed  by  anything  more  serious  than  swelling 
and  ecchymosis  of  the  lids  and  extravasation  of  blood 


492 


PREVALENT    DISEASES    OF    THE     EYE. 


beneath  the  conjunctiva  and  into  the  loose  cellular 
tissue  of  the  orbit.  When  we  consider  the  delicate 
structure  of  the  eve  it  is  indeed  surprising  to  what  rough 
usage  it  may  be  subjected  without  serious  injury. 
However,  it  is  only  sound  eyes  that  exhibit  such  im- 
munity.    Myopic  eyes,  as  has  been  stated  already,  are 


->^ 


:^^ 


Fig.  182. — Radiating  and  pupillary  rupture  of  the  iris  (Hansell  and  Sweet). 


Fig.  1S3. — Iridodialysis  caused  by  the  explosion  of  a  firecracker  (Lawson). 

especially  liable  to  be  seriously  damaged  by  compara- 
tively trivial  traumatisms,  and  so  are  those  which  have 
suffered  from  previous  attacks  of  iritis,  choroiditis,  etc. 
Opacity  of  the  lens,  traumatic  cataract,  is  one  of  the 
not  uncommon  results  of  severe  contusions  of  the  eye. 
And  this  may  happen  without  rupture  of  the  lens  cap- 


INJURIES    OF    THE    EYE    AND    APPENDAGES.         493 

sule,  simply  from  the  concussion  to  which  the  eye  is 
subjected.  Mydriasis  and  loss  of  the  power  of  accom- 
modation from  paralysis  of  the  sphincter  pupillne  and 
the  ciliary  muscle,  usually  transient,  also  occur.  Hem- 
orrhage into  the  anterior  chamber,  and  marked  ex- 
ophthalmos from  extravasation  of  blood  into  the  cellular 
tissue  of  the  orbit,  are  observed,  and  rarely  such  injury 
of  the  muscles  or  motor  nerves  of  the  eve  as  may  lead 
to  the  production  of  squint.  Injury  of  the  lacrimal  sac 
and  nasal  duct  from  blows  is  not  unusual,  and  may 
result  in  occlusion  of  the  duct  and  persistent  and  annoy- 
ing epiphora. 

Among  the  commoner  causes  of  severe  contusions  of 
the  eye  may  be  mentioned  blows  from  flying  chips  in 
chopping  and  splitting  wood,  from  stones  thrown  by 
accident  or  design,  from  pebbles  or  bullets  shot  from 
air-guns,  from  nails  awkwardly  struck,  from  hmbs  ot 
trees,  and  from  corks  driven  with  violence  from  cham- 
pagne or  soda-water  bottles.  In  one  instance  I  saw  an 
eye  that  was  irreparably  damaged  from  having  been 
struck  by  a  "ball"  from  a  Roman  candle,  which  had 
been  foolishly  aimed  at  a  party  of  boys. 

Treatment. — This  will  depend,  of  course,  upon  the 
nature  of  the  injury,  which  may  be  so  severe  as  to  de- 
mand immediate  enucleation  of  the  damaged  eye,  or 
so  trivial  as  to  call  only  for  the  application  of  ice-cloths 
and  a  few  days'  rest  from  work.  The  lotion  of  opium 
and  boracic  acid  is  a  most  useful  application,  and  atro- 
pin  is  often  indicated,  especially  when  the  iris  is  injured. 
Sodium  salicylate,  in  liberal  doses,  has  a  marked  influence 
in  controlling  supervening  inflammation,  particularly 
of  the  deeper  structures  of  the  eye. 

In  severe  contusions  of  the  eye  the  danger  of  sympa- 
thetic ophthalmitis  should  not  be  lost  sight  of,  the  cases 


494  PREVALENT    DISEASES    OF    THE    EYE. 

in  which  this  is  most  to  be  feared  being  those  in  which 
rupture  of  the  tunics  has  occurred,  with  subsequent 
partial  atrophy  of  the  ball.  Enucleation  of  the  injured 
eye  is  indicated  under  such  circumstances,  and  should 
not  be  unnecessarily  deferred. 

Penetrating  wounds  of  the  eye  are  always  of 
serious  concern,  not  only  because  of  the  immediate  dam- 
age involved  and  the  inflammation  liable  to  supervene, 
but  because  of  the  danger  of  infection  of  the  wound, 
which,  once  established,  is  very  apt  to  end  in  destructive 
panophthalmitis. 

Penetrating  wounds  of  the  cornea  often  involve  the 
iris  and  not  infrequently  the  lens,  and  when  this  is  the 
case  prolapse  of  the  iris  and  traumatic  cataract  usually 
result.  Wounding  of  the  lens  constitutes  a  grave  com- 
plication, not  only  because  of  the  ultimate  effect  upon 
vision,  but  because  the  svN^elling  of  the  lens,  which  usually 
quickly  supervenes,  adds  materially  to  the  risk  of  serious 
inflammation  of  the  iris  and  ciliary  body.  It  may 
also  give  rise  to  a  glaucomatous  condition  of  the  eye, 
resulting,  if  not  soon  controlled,  in  permanent  damage 
to  the  optic  nerve  and  retina.  Incised  wounds  of  the 
cornea  which  do  not  involve  the  iris  or  lens  usually  do 
well,  though  they  not  infrequently  give  rise  to  displace- 
ment of  the  pupil  and  to  the  formation  of  an  anterior 
synechia.  If  central,  they  are  apt  to  impair  vision 
markedly,  because  of  the  resulting  opacity  and  disturb- 
ance of  the  corneal  curvature. 

Wounds  of  the  sclera  and  ciliary  body  are  of  grave 
import,  and  are  often  complicated  by  hernia  of  the 
ciliary  body  or  iris  (Fig.  184)  and  prolapse  of  the 
vitreous  humor.  Infection  is  especially  apt  to  occur 
under  such  circumstances,  since  the  vitreous  humor 
furnishes  an  admirable  culture  medium  for  the  growth 
of  pyogenic  bacteria. 


INJURIES    OF    THE    EYE    AND    APPENDAGES.        495 

Penetrating  wounds  of  the  sclera,  back  of  the  ciliary 
region,  though  they  usually  involve  the  choroid  and 
retina,  are  commonly  not  so  serious  in  their  conse- 
quences as  are  those  of  the  ciliary  body.  If,  however, 
infection  occurs  they  result  disastrously,  and,  even 
without  this  happening,  if  they  are  extensive  and  lac- 
erated, they  usually  lead  to  loss  of  sight  and  ultimately 
to  atrophy  of  the  eyeball  (Fig.  185). 

Treatment. — In  view  of  the  attendant  dangers,  and 
the  serious  complications  liable  to  occur,  the  treatment 
of  penetrating  wounds  of  the  eye  should  be  consigned,  if 


Fig.  1S4. — Rupture  of  the  sclera  with  incarceration  of  the  iris  from  a  blow 

(Lawson). 

practicable,  to  the  hands  of  the  specialist.  For,  in  the 
first  place,  the  question  whether  it  is  worth  while  to 
attempt  to  save  the  eye,  whether  immediate  enucleation 
is  advisable  or  not,  often  presents  itself.  Then,  if  there 
is  a  prospect  of  saving  the  eye,  careful  antiseptic  pre- 
cautions are  called  for,  and,  very  probably,  the  abscis- 
sion or  replacement  of  prolapsed  portions  of  the  iris  or 
ciliary  body,  or  possibly  the  extraction  of  a  wounded  or 
dislocated  lens. 

As  a  "first  aid"  in  such  cases,  the  lids  and  the  eye 
itself  should  be  gently  bathed  with  a  i :  8000  sublimate 


496  PRKVALFNT    DISEASES    OF    THE     EYE. 

solution,  and  a  gauze  pad,  wet  with  the  same  solution 
or  a  sterilized  lotion  of  opium  and  boracic  acid,  should 
be  applied  over  the  closed  lids,  and  kept  in  place  by  a 


Fig.  185. — Atrophy  of  the  eyeball,  the  result  of  severe  iridocyclitis  caused 
by  a  penetrating  wound  (Fuchs,  in  part  after  Wedl-Bock).  The  umbrella- 
like (the  usual  form  of)  detachment  of  the  retina  is  well  shown.  The 
eye  is  smaller  and  of  irregular  shape,  chiefly  from  the  wrinkling  of  the 
sclera,  S,  behind  the  points  of  attachment  of  the  ocular  muscles,  the 
rectus  internus,  ri,  and  the  rectus  externus,  re.  The  cornea,  C,  is 
diminished  in  size,  flattened,  and  wrinkled  especially  on  its  posterior 
surface.  At  its  inner  border  it  bears  the  depressed  cicatrix,  N,  which  was 
produced  by  the  injury.  The  anterior  chamber  is  shallow;  the  iris,  i,  is 
thickened  and  forms  an  unbroken  surface,  because  the  pupil  is  closed  by 
exudate.  Behind  the  iris  lies  the  shrunken  lens,  /,  and  behind  this  is  the 
great  hull  of  cyclitic  membrane,  c,  the  shrinking  of  which  is  the  cause  of 
the  atrophy  of  the  eyeball.  By  reason  of  this  shrinking,  the  ciliary  pro- 
cesses, the  pigment  layer  of  which  has  markedly  proliferated,  are  drawn 
in  toward  the  center,  and,  together  with  the  adjacent  choroid,  ch,  are 
detached  from  the  sclera;  between  the  two  structures  are  seen  the  dis- 
joined lamella;  of  the  suprachoroid  membrane,  a.  The  retina,  r,  is  de- 
tached and  folded  in  the  form  of  a  funnel,  which  incloses  the  remains  of 
the  degenerated  vitreous,  g.  The  subretinal  space,  s,  is  filled  vrith  a  fluid 
rich  in  albumin.     The  optic  nerve,  0,  is  thinner  than  usual  and  atrophic. 

light  bandage.     And  here,  if  practicable,  as  I  have  said, 
the  general  practitioner's  care  of  the  case  should  cease. 


INJURIES    OF    THE    EYE    AND    APPENDAGES.         497 

If,  in  spite  of  antiseptic  precautions,  definite  signs  of 
infection  of  the  eye  exhibit  themselves,  enucleation  is 
commonly  indicated,  and,  if  promptly  performed,  will 
save  much  unnecessary  suffering.  As  has  already  been 
pointed  out,  the  danger  of  cerebral  or  general  infection 
is  not  appreciably  greater  from  operating  under  such 
circumstances  than  from  permitting  the  panophthal- 
mitis to  run  its  tedious  course.  There  is  also  the  risk  of 
sympathetic  ophthalmitis  from  extensive  wounds  of  the 
cornea  and  iris,  or  of  the  sclera  and  ciliary  body,  and 
this  is  another  reason  why,  if  there  is  no  prospect  of 
useful  vision  being  preserved,  enucleation  should  be 
resorted  to  without  unnecessary  delay. 

Wounds  of  the  Eye  Complicated  by  the  Lodgment 
of  Foreign  Bodies  within  the  Ball. — The  dangers 
attendant  upon  penetrating  wounds  of  the  eye  are 
greatly  increased  by  the  lodgment  of  a  foreign  body 
within  the  ball.  In  the  first  place,  the  risk  of  infection 
is  much  greater  (see  Fig,  130),  and,  even  if  this  does 
not  occur,  the  irritation  caused  by  the  continued  pres- 
ence of  the  foreign  body  is  almost  certain  to  set  up  an 
insidious  inflammation  of  the  deeper  structures  of  the 
eye,  which  ends  in  loss  of  sight.  Again,  there  is  greater 
probability  of  sympathetic  ophthalmitis  supervening. 
Indeed,  this  dreaded  complication  is  more  often  due  to 
the  presence  of  a  foreign  body  in  the  primarily  affected 
eye  than  to  any  other  cause. 

Much  depends,  it  is  true,  upon  the  nature  of  the 
foreign  body,  and  upon  its  position  within  the  ball. 
Foreign  bodies  which,  though  sterile,  undergo  chemical 
changes,  such  as  bits  of  iron  or  steel  or  copper,  are  most 
apt  to  give  rise  to  disastrous  consequences.  On  the 
other  hand,  spicules  of  glass  or  small  fragments  of  stone 
are  not  so  surely  destructive  of  sight,  since  they  may 
32 


49^  PREVALENT    DISEASES    OF    THE    EYE. 

become  encysted,  and  in  this  way  be  rendered  innoc- 
uous. A  striking  case  of  this  character  has  come  under 
my  observation,  in  which  a  small  piece  of  glass,  after 
entering  the  anterior  chamber,  fell  through  the  pupil, 
and  lodged  in  the  ciliary  processes.  Sharp  inflamma- 
tor}'  reaction  followed,  but  soon  subsided,  and  evidently 
resulted  in  the  glass  becoming  encysted;  and  to  this  day, 
the  accident  having  occurred  more  than  thirty  years  ago, 
no  ill  effects  have  been  experienced,  the  injured  eye 
being  as  free  from  irritation,  and  as  capable  of  perform- 
ing its  daily  task,  as  its  fellow. 

As  to  the  influence  of  location,  a  foreign  body  lodged 
within  the  lens  capsule,  although  almost  sure  to  cause 
the  development  of  cataract,  may  not  provoke  inflam- 
matory complications,  and  this,  in  less  measure,  is  true 
of  one  suspended  in  the  vitreous  humor.  As  opposed 
to  this,  a  foreign  body  embedded  in  the  iris,  ciliary 
body,  or  choroid  is  more  certain  to  excite  destructive 
inflammation,  and  is  also  more  apt  to  cause  sympathetic 
implication  of  the  fellow-eye.  Wounds  of  the  eye  from 
bird-shot  are  especially  dangerous,  partly  from  the 
character  of  the  wound,  and  partly  from  the  nature  of 
the  foreign  body. 

In  order  to  penetrate  the  tunics  of  the  eye  a  foreign 
body  must  have  considerable  weight  relatively  to  its 
size,  and  must  be  driven  with  great  force.  This  is 
especially  true  of  those  that  impinge  upon  the  very 
tough  sclera,  which  is  less  frequently  penetrated  than 
the  cornea.  Foreign  bodies  which  pass  through  the 
sclera  commonly  fall  into  the  vitreous  chamber,  and 
in  time  come  to  rest  upon  the  retina,  at  the  bottom  of  the 
eveball.  Those  which  enter  through  the  cornea  excep- 
tionally fall  into  the  anterior  chamber,  but  more  often 
lodge  in  the  iris  or  pass  through  it  into  the  vitreous 


INJURIES    OF    THE    EYE    AND    APPENDAGES.        499 

body,  frequently  wounding  the  lens  in  their  course,  and 
giving  rise  to  a  traumatic  cataract  (Fig.  i86).  Those 
which  lie  loose  in  the  anterior  chamber  usually  excite 
iritis,  and  eventually  become  encysted  in  the  narrow 
space  between  the  lower  margin  of  the  iris  and  the 
cornea. 

Treatment. — Before  the  days  of  the  electro-magnet 
and  skiagraphy,  the  lodgment  of  a  foreign  body  within 
the  eyeball  usually  meant  loss  of  sight  and,  sooner  or 
later,  enucleation  of  the  eye.  Nowadays,  many  such 
eyes  are  saved,  and  often  with  useful  vision.     By  means 


Fig.   186. — Spicule  of   iron  in  the  vitreous  (extracted);    laceration  of    the 
iris,  traumatic  cataract,  and  turbidity  of  the  vitreous  (Haab). 

of  skiagraphy  the  exact  location  of  nearly  all  foreign 
bodies  can  be  determined,  and  this,  it  is  evident,  greatly 
facilitates  their  removal  (Figs.  187,  188,  189).  By  the 
help  of  the  magnet  bits  of  iron  and  steel  (and  they 
constitute  a  very  large  proportion  of  the  foreign  bodies 
which  enter  the  eye),  in  most  instances,  can  be  extracted, 
and,  not  infrequently,  so  as  to  leave  a  serviceable  eye. 
For  this  purpose  the  powerful  electro-magnet  of  Sweet 
is  the  instrument  I  have  found  most  effective 
(Fig.  190). 


500  PREVALENT    DISEASES    OF    THE    EYE. 

By  means  of  oblique  illumination  foreign  bodies  lying 
in  the  anterior  chamber  or  superficially  in  the  lens,  or 
that  are  partially  embedded  in  the  iris,  can  usually 
be  detected  without  difficulty,  unless,  as  sometimes  hap- 
pens, they  are  hidden  by  hemorrhage;  but  only  excep- 
tionally can  those  that  have  passed  into  the  vitreous 
chamber  be  discovered,  for  in  most  instances  the  media 


Fig.  187. — Sweet's  apparatus  for  localizing  foreign  bodies  in  the  eye  with  the 

Rontgen  rays. 

are  too  cloudy  to  permit  of  a  satisfactory  ophthalmo- 
scopic examination.  And  it  is  here  that  skiagraphy 
proves  invaluable.  When  this  test  is  not  available  the 
"pain  reaction"  test  may  be  employed,  provided  the 
foreign  body  is  magnetic.  This  consists  in  approach- 
ing a  strong  magnet  very  close  to  the  eye,  or  bringing  it 


INJURIES    OF    THE    EYE    AND    APPENDAGES.        5OI 

in  actual  contact  with  it.  The  pull  which  it  exerts 
upon  fragments  of  iron  or  steel,  especially  if  they  are 
of  considerable  size,  usually  causes  decided  pain. 
A  negative  result  does  not  definitely  exclude  the  pres- 
ence of  a  magnetizable  foreign  body,  but,  at  least,  it 
renders  it  improbable. 

In  every  case  in  which  there  is  reason  to  fear  that  a 
foreign  body  has  entered  the  eye  the  tests  described — 


Fig.   188. — Radiograph  showing  foreign  body  (Sweet). 


especially  the  skiagraphic  test — should  be  employed 
with  as  little  loss  of  time  as  possible;  for  the  sooner  it  is 
discovered  and  removed  the  greater,  other  things  being 
equal,  is  the  likelihood  of  saving  the  eye.  In  the  mean- 
time, until  the  case  can  be  placed  in  the  hands  of  a 
specialist,  antiseptic  measures,  such  as  have  been  men- 
tioned in  connection  with  the  treatment  of  penetrating 
wounds  of  the  eye,  should  be  employed,  a  sterilized  four- 
grain  solution  of  atropin  (Fig.  191)  should  be  instilled 


502 


PREVALENT    DISEASES    OF    THE     EYE. 


every  three  or  four  hours,  and  the  eye  should  be  closed 
with  a  pad  of  gauze,  v^^et  with  a  i  :  8000  sublimate 
solution,  or  a  sterilized  lotion  of  opium  and  boracic 
acid,  and  a  light  bandage. 

Non-magnetic  foreign  bodies  should  be  located,  if 
possible,  by  means  of  oblique  illumination,  the  ophthal- 
moscope, or  skiagraphy,  and  removed,  through  a  suit- 
ably placed  incision,  with  toothless  forceps,  a  traction 
hook,  or  a  small  curet. 


Name 
Date_ 


Size  of  body hy ^by ^mm. 

Situation 
miRhack  of  center  of  comea. 
__mmJt)  eIdw  horizantal  plane . 
side  of 


,inin.ta_ 


vertical  plane. 


/r     iJ-'-r^  :  HarizoTital 
section. 


Side  view. 


Front  view. 


Froat  view. 


Side  view. 


Fig.   189. — Reduced  drawing  of  Dr.   Sweet's  localizing  chart,   illustrating 
method  of  plotting  position  of  foreign  body  in  the  eyeball. 

The  removal  of  foreign  bodies  from  the  anterior 
chamber  is  not  so  easily  accomplished  as  might  appear 
at  first  sight.  If  magnetic  they  may,  perhaps,  be  drawn 
out  with  a  strong  magnet  through  the  wound  of  en- 
trance or  through  an  incision  made  for  the  purpose. 
If  they  can  not  be  removed  in  this  way,  they  must  be 
extracted  with  toothless  forceps;     but  as  the  aqueous 


INJURIES    OF    THE    EYE    AND    APPENDAGES.         503 

humor  escapes,  and  the  anterior  chamber  is  obliterated, 
as  soon  as  an  incision  is  made  in  the  cornea,  this  is  often 
a  difficult  procedure.  Indeed,  when  the  foreign  body  is 
embedded  in  the  iris  it  is  frequently  necessary  to  remove 
the  portion  of  the  iris  to  which  it  is  attached — that  is  to 
say,  to  perform  an  iridectomy. 

In  an  unusual  case  which  came  under  my  observation 
some  years  since,  as  the  result  of  a  blow  from  a  chip  of 
wood  an  eyelash  was  driven  through  the  cornea  into 
the  anterior  chamber,  and  lay,  across  the  pupil,  upon 


Fig.   190. — Sweet's  electro-magnet. 

the  surface  of  the  iris.  With  considerable  difficulty 
it  was  removed  through  a  peripheral  corneal  incision, 
without  injury  to  the  iris,  and,  though  a  slight  anterior 
synechia  was  left,  useful  vision  was  preserved. 

Exceptionally,  and  particularly  in  gunshot  wounds, 
a  foreign  body  may  pass  through  the  posterior,  as  well  as 
the  anterior,  coats  of  the  eye,  and  lodge  in  the  orbit, 
and  in  other  exceptional  instances  it  may  lodge  in  the 
orbit    without    wounding    the  eyeball.       Its    removal. 


504  PREVALENT    DISEASES    OF    THE    EYE. 

under  such  circumstances,  is    difficult  of  accomplish- 
ment, and  may  not  be  necessary,  unless    it  proves  a 
source  of  irritation. 

Wounds  of  the  eyeball  caused 
by  penetrating  foreign  bodies 
are  sometimes  so  extensive  or  of 
such  a  character  that  enucleation 
is  clearly  called  for,  the  mere 
removal  of  the  foreign  body 
offering  no  hope  of  preserving 
sight.  This  is  especially  true  of 
lacerated  wounds  of  the  cornea 
and  ciliary  region,  such  as  are 
produced  by  jagged  pieces  of  iron 
or  steel,  struck  from  the  edge  of 
a  hammeror  chisel,  flying  against 
the  eye  with  great  force.  In 
such  cases  removal  of  the  eye  is 
Fig.  igi^^^rence  flask  ^he  only  procedure  to  be  thought 
for  sterilizing  coiiyria  (about  of;  and  it  can  not  be  done  too 
two-thirds  actual  size).     See  quickly,  for  delay  means  not  Only 

foot-note.*  ^  J  ^  .'  _  / 

much  needless  suffering,  but  the 
added  risk  of  sympathetic  ophthalmitis. 

*  This  flask,  fitted  with  a  "  Barnes  eve-dropper,"  I  greatly  prefer  to 
the  Stroschein  flask  commonly  used,  for  it  is  not  only  less  expensive, 
but  much  less  fragile.  The  mouth  of  the  flask  is  plugged  with  cotton, 
in  the  usual  manner,  when  the  solution  is  being  boiled.  The  eye- 
dropper  is  boiled  separately,  and,  when  the  solution  has  cooled,  is  fitted 
quickly  into  the  flask.  The  neck  of  the  i -ounce  flasks,  as  they  are 
found  on  the  market,  is  too  large  to  fit  the  Barnes  eye-dropper;  but 
Messrs.  Whitall,  Tatum  &  Co.,  of  Philadelphia,  who  furnish  them, 
will  "  draw  it  in  "  to  the  size  desired. 


APPENDIX. 


The  following  formulae,  for  the  most  part  in  general 
use,  are  indicated,  and  will  be  found  efficacious,  in  the 
conditions  mentioned. 

COLLYRIA. 
To  be  applied  by  means  of  an  eye-dropper,  preferably 
one  with  a  bent  tip.  Except  when  solutions  of  atro- 
pin,  hyoscyamin,  and  other  such  poisonous  drugs  are 
prescribed,  they  may  be  instilled  freely,  and  it  is  not 
necessary  to  direct  exactly  how  many  drops  should  be 
used. 

Acid,  boracic gr.  x 

Aquae  destil § j. 

A  few  drops  three  or  four  times  a  day. 

Hyperemia  of  the  conjunctiva,  mild  conjunctivitis, 
inflammation  of  the  conjunctiva  following  injuries, 
operations,  the  intrusion  of  foreign  bodies,  etc.,  and  for 
the  relief  of  smarting  and  burning  of  the  eyes. 

Acid,   boracic gr.  x 

Aquae  camphor 5ij 

Aquae  destil ovj. 

A  few  drops  three  or  four  times  a  day. 
Hyperemia  of  the  conjunctiva,  and  for  the  relief  of 
smarting  and  burning  of  the  eyes. 

Sodii  chlorid gr.  iij-v 

Aquae  destil 5  j. 

Indicated  in  the  same  conditions,  and  to  be  used  in 
the  same  manner,  as  the  foregoing. 

505 


506  PREVALENT    DISEASES    OF    THE     EYE. 

Acid,   boracic gr.  xviij 

Aq.   destil O j- 

For  cleansing  the  eve  and  for  instillation  everv  hour 
or  half  hour  in  purulent  ophthalmia,  and  for  less  fre- 
quent instillation,  in  connection  with  other  remedies, 
in  ulcerative  and  suppurative  keratitis. 

Zinci  sulphat gr-  ss 

Acid,  boracic gr.  x 

Aquae  destil 5  j- 

A  few  drops  three  times  a  day. 
Catarrhal  and  follicular  conjunctivitis. 

Hydrarg.  bichlorid gr.    j^ 

Sodii  chlorid gr.  iij-v 

Aqure  destil 5j- 

A  few  drops  three  times  a  day. 

Vernal  catarrh,  follicular  conjunctivitis,  and  blennor- 
rhea of  the  lacrimal  sac.  In  the  last-mentioned  con- 
dition, to  be  dropped  into  the  inner  corner  of  the  eve, 
after  pressing  out  the  contents  of  the  sac. 

Alum gf-  'U 

Acid,   boracic gr.  xij 

Aquae  destil 5 j. 

A  few  drops  morning  and  night. 

For  habitual  application  to  the  conjunctival  sac  when 
an  artificial  eye  is  being  worn. 

Sol.  Protargol 40% 

For  daily  application,  with  cotton  mop  or  eye-dropper, 
in  purulent  ophthalmia,  and  every  second  day  in  acute 
stage  of  trachomatous  conjunctivitis. 

Sol.    Argyrol 40%  to   50% 

Indications  the  same.  May  be  applied  as  often  as 
three  times  a  day  in  purulent  ophthalmia. 


APPENDIX.  507 

Sol.    Protargol 10% 

For  application  twice  daily  in  purulent  ophthalmia, 
in  addition  to  the  daily  application  of  the  stronger  solu- 
tion, and  for  use,  two  or  three  times  a  day,  in  trachoma- 
tous conjunctivitis. 

Sol.   Argyrol 20% 

Indications  the  same.     May  be  used  more  freely. 

Sol.  Argyrol 5%  or 

Protargol 2% 

Drop  into  the  inner  corner  of  the  eye  three  times  a 
day,  after  pressing  out  the  contents  of  the  lacrimal  sac. 
Blennorrhea  of  the  lacrimal  sac. 

Aqua  chlorinii  (freshly  prepared). 

To  be  dropped  into  the  eye,  if  practicable  upon  the 
cornea,  every  three  hours. 

Infected  corneal  ulcer,  whether  of  idiopathic  or  trau- 
matic origin. 

Holocain  hydrochlorat gr.  j 

Acid,  boracic gr.  x 

Aquae  destil §  j. 

A  few  drops  every  three  hours. 
Ulcer  of  cornea. 

Atropiae  sulphat gr.  j 

Acid,  boracic gr.  x 

Aquae  destil 5 j- 

One  or  two  drops  three  times  a  day. 
Phlyctenular  conjunctivitis  and  keratitis  and  other 
mild  forms  of  keratitis. 


508  PREVALENT    DISEASES    OF    THE    EYE. 

Atropiae    sulphat gr.  ij 

Acid,    boracic gr.  x 

Aquae  destil 5 j- 

In  like  conditions,  when  photophobia  and  lacrimation 
are  more  marked. 

Atropia?  sulphat gr.  iv 

Acid,  boracic gr.  x 

Aquae  destil §  j. 

One  or  two  drops  every  three  hours. 

Iritis,  cycHtis,  severe  keratitis,  or  sclero-keratitis,  and, 
three  times  daily,  in  episcleritis,  sclero-conjunctivitis, 
and  interstitial  keratitis. 

Atropiae  sulphat gr.  j 

Acid,  boracic gr.  x 

Aquae  destil 5  j- 

One  or  two  drops  every  third  day. 

To  improve  the  vision  in  incipient  cataract,  when  the 
opacity  of  the  lens  is  chiefly  central,  by  maintaining 
semi-dilation  of  the  pupil. 

Atropiae  (alk.) gr-  iv 

01.   ricini oj- 

One  or  two  drops  three  or  four  times  a  day. 
Burns  of  the  cornea  and  conjunctiva. 

Eserin    sulphat gr.  ij-iv 

Acid,  boracic gr.  x 

Aquae  destil O j- 

One  or  two  drops  three  or  four  times  a  day. 
Inflammatory  glaucorha. 

Eserin  sulphat gr.  |— J 

Acid,  boracic gr.  x 

Aquae  destil O j- 

One  or  two  drops  morning  and  night. 
Glaucoma  simplex,  chronic  glaucoma,  and  in  inflam- 
matory glaucoma  between  exacerbations. 


APPENDIX. 


509 


PiloCarpin  hydrochlorat gr.  iv-viij 

Acid,  boracic gr.  x 

Aquae  destil 5 j- 

One  or  two  drops  three  or  four  times  a  day. 
Inflammatory    glaucoma,    when    eserin    is    not   well 
borne. 

Pilocarpin  hydrochlorat gr.  j-ij 

Acid,  boracic gr.  x 

Aquae  destil O j- 

One  or  two  drops  two  or  three  times  a  day. 

As  a  substitute  for  the  weaker  solution  of  eserin,  in 
glaucoma  simplex,  chronic  glaucoma,  and  in  inflamma- 
tory glaucoma  between  exacerbations. 

Sol.  Dionin 5% 

One  or  two  drops  two  or  three  times  a  day. 

Iritis  and  keratitis,  in  conjunction  with  atropin,  in- 
flammatory glaucoma,  in  conjunction  with  eserin,  and 
to  promote  the  absorption  of  recent  corneal  opacities, 
of  inflammatory  exudates  in  the  anterior  chamber,  and 
of  extruded  cortical  lens  substance,  after  cataract 
operations  or  wounds  of  the  lens. 

Hyoscyamin  hydrobromat gr.  ij 

Aquae  destil S  i- 

One  or  two  drops  every  three  or  four  hours. 

Iritis,  keratitis,  etc.,  as  a  substitute  for  atropin,  when 
atropin  is  not  well  borne.  Also  as  a  cvcloplegic  in 
determinino;  refractive  errors.  When  used  for  this 
purpose,  two  applications  of  a  single  drop,  an  hour  or 
two  apart,  should  be  made  the  evening  before,  and 
three  applications,  at  similar  intervals,  during  the  fore- 
noon of,  the  day  on  which  the  examination  is  to  be  made. 


510  PREVALENT    DISEASES    OF    THE     EYE. 

Homatropiae  hydrobromat gr.  ij 

Aquas  dcstil 3ij- 

An  evanescent  and  but  slightly  toxic  cycloplegic,  used 
in  measuring  refractive  errors.  Three  applications  at 
half-hour  intervals  the  evening  before,  and  seven  or 
eight  applications  the  morning  of,  the  examination,  the 
last  three  twenty  minutes  apart,  the  others  at  intervals 
of  an  hour. 

Homatropiae  hydrobromat gr.  ij 

Aquae  destil 5ss. 

One  or  two  applications. 

An  evanescent  mydriatic.  To  facilitate  ophthalmo- 
scopic examinations,  to  permit  inspection  of  the  lens 
in  suspected  cataract,  and  to  determine  the  presence  of 
iritis. 

Euphthalmin  hydrochlorat gr.  vj 

Aquae  destil .^. oij- 

A  transient  mydriatic,  to  be  used  in  the  same  way, 
and  for  the  same  purposes,  as  the  foregoing. 

Cocain  hydrochlorat gr.  xx  (4%) 

Acid,  boracic g^"-  ''v 

Aquae  destil § j. 

Three  to  five  applications,  at  intervals  of  two  or  three 
minutes. 

To  induce  anesthesia.  In  all  important  operations 
should  be  sterilized  by  boiling  before  being  used.  Dis- 
tinctly objectionable,  and  not  to  be  employed,  as  a 
therapeutic  agent. 


APPENDIX. 


511 


Holocain  hydrochlorat gr.  x  (2%) 

Aquae  destil oj. 


A  local  anesthetic,  to  be  applied  in  the  same  manner 
as  cocain,  and  to  be  used  as  a  substitute  for  it  when  it  is 
desirable  to  avoid  the  mydriasis  and  the  disturbance  of 
the  corneal  epithelium  which  cocain  produces.  Is  in 
itself  an  antiseptic. 

Sol.   Hydrarg.    bichlorid i  :  8000. 

For  sterilizing  the  eye  preparatory  to  operations. 
Several  hours  before  the  time  fixed  for  the  operation 
the  lids  should  be  cleansed  with  soap  and  water,  the 
conjunctival  sac  flushed  with  this  solution,  and  a  gauze 
pad  wet  with  it  bound  over  the  lids.  The  flushing  of 
the  conjunctiva  should  be  repeated  three  times,  at  inter- 
vals of  about  an  hour,  before  the  operation  is  begun. 


LOTIONS. 

To  be  applied  on  absorbent  gauze,  or  soft  linen,  pads 
over  the  closed  lids. 


Saturated  Solution  of  Boracic  Acid. 

Acid,  boracic gr.   Ixxij 

Aquae   destil 3iv. 

Useful  in  wounds  of  the  lids  and  eyeball,  after  enucle- 
ation of  the  eye,  in  lid  abscess,  etc.  By  covering  the 
pad  with  oiled-silk  or  oiled-muslin  a  cleanly  and  excel- 
lent poultice  is  provided. 


512  PREVALENT    DISEASES    OF    THE     EYE. 

Lotion  of  Opium  and  Boracic  Acid. 

(Frequently  commended  in  the  text.) 

Ext.  opii gr.  X 

Acid,   boracic gr.  xl 

Aq.  destil 5iv. 

Valuable  in  any  painful  condition  of  the  eye,  espe- 
cially in  traumatic  lesions,  in  keratitis,  iritis,  glaucoma, 
acute  inflammation  of  the  lacrimal  sac,  lid  abscess,  pan- 
ophthalmitis, cellulitis  of  the  orbit,  etc.  Also  useful  in 
asthenopia,  in  miliary  choroido-retinitis,  dependent 
upon  strain  of  accommodation,  and  in  the  choroido- 
retinitis  of  high  myopia.  May  be  given  a  poultice-like 
action  by  covering  the  pad  on  which  it  is  applied  with 
oiled-silk  or  oiled-muslin.  May  be  applied  hot  if  found 
more  soothing. 

Lotion  of  Belladonna. 

Ext.  belladonnae gr.  xv 

Aquae  destil ^iw 

Iritis,  cyclitis,  keratitis,  etc. 

Sublimate  Solution. 

Hydrarg.  bichlorid gr.  j 

Aquae  destil Oj. 

Wounds  of  the  lids  and  eyeball.  The  lids  should  first 
be  bathed,  and  the  conjunctival  sac  flushed,  with  this 
same  solution. 

Hot  Water. 

Interstitial  keratitis,  iritis,  and  glaucoma.  Should 
be  applied  as  hot  as  can  be  borne  without  complaint. 

Iced  Water. 

Pads  of  gauze  should  be  kept  lying  upon  a  block  of 


APPENDIX.  513 

ice,  and  a  fresh  pad  should  be  appHed  to  the  eye  at  short 
intervals. 

Purulent  ophthalmia  in  the  adult. 


OINTMENTS. 

"Vaselin  Cerate." 

Cerae  flav i   part 

Vaselin 4  parts. 

To  be  melted  together,  and  stirred  while  cooling. 

A  useful  base,  of  proper  consistency  and  with  little 
tendency  to  become  rancid,  for  ointments  to  be  applied 
to  the  lids. 

Hydrarg.  ox.  flav gr.  viij 

Vaselin  cerate 5ss. 

To  be  applied  to  the  lids  at  bedtime,  after  removing 
any  crusts  that  may  be  present  by  bathing  with  warm 
water. 

Blepharitis  marginalis  and  eczema  of  the  lids. 

Hydrarg.  ox.  flav gr.  iv 

Vaselin 5ss. 

A  piece  the  size  of  a  rice-grain  to  be  applied  to  the  eye 
once  a  day,  preferably  in  the  morning.  The  appHcation 
can  be  conveniently  made  with  a  flat  wooden  toothpick 
or,  by  untrained  hands,  with  a  small  camel's-hair  brush. 

Phlyctenular  conjunctivitis  and  keratitis,  vernal 
catarrh,  chronic  trachoma  with  pannus. 

Zinci  oxid. 

Acid,  boracic aa  5ss 

Vaselin  cerate §ss. 

To  be  applied  morning  and  night. 

33 


514  PREVALENT    DISEASES    OF    THE    EYE. 

Eczema  of  the  lids. 

Acid,  salicylic gr.  iv-viij 

Vaselin  cerate 5ss. 

To  be  applied  morning  and  night. 

Eczema  of  the  lids,  and,  exceptionally,  in  blepharitis 
marginalis,  when  the  yellow  oxid  of  mercury  ointment 
fails  to  cure. 

Ext.  belladonnae 3j 

Ung.  hydrarg 5 j. 

To  be  rubbed  upon  the  forehead  and  temples  three 
times  a  day. 

Syphilitic  iritis  and  irido-cyclitis,  sympathetic  ophthal- 
mitis. 


AGENTS  TO  BE  APPLIED,  WITH  EXACTNESS,  TO  THE  EYE 

OR  LIDS. 

Acid,  carbolic. 

For  application  to  infected  corneal  ulcers  or  wounds, 
and  to  abort  styes. 

A  very  small  quantity  of  the  acid  should  be  applied 
directly  to  the  ulcer  (the  eye  being  under  the  influence 
of  cocain)  by  means  of  a  sharp-pointed,  wooden  tooth- 
pick, armed  with  a  few  fibers  of  absorbent  cotton. 
After  the  application  the  eye  should  be  flushed  with  a 
boracic  acid  or  normal  salt  solution.  In  the  treatment 
of  styes,  the  point  of  the  toothpick,  after  having  been 
dipped  into  the  acid,  should  be  insinuated  as  far  as 
possible  into  the  infected  follicle,  which  can  generally 
be  recognized  upon  the  Hd-margin. 

Tinct.  iodin. 


APPENDIX.  515 

To  be  applied  in  the  same  careful  way  as  carbolic 
acid. 

Infected  corneal  ulcers. 

Zinci  sulphat gr.  xxx 

Aquae  destil O j- 

Should  be  applied  with  the  finger-tip,  every  half-hour, 
to  the  external  surface  of  the  lid,  over  the  sensitive  area, 
care  being  exercised  not  to  let  the  solution  enter  the  eye. 

To  abort  styes. 

Pointed  crayon  of  silver  nitrate. 

To  be  applied  lightly  to  the  lid-margin  after  removal 
of  crusts. 

Blepharitis  marginalis. 

Copper  sulphate  crystal. 

For  application  to  the   conjunctival  surface  of  the 
everted  lids,  every  second  or  third  day. 
Chronic  trachomatous  conjunctivitis. 

Veratriae  Oleat 10% 

A  little  to  be  rubbed  upon  the  forehead  and  temples 
once  a  day,  preferably  in  the  morning.  Care  should  be 
exercised  to  prevent  its  getting  into  the  eye,  as  this 
causes  severe  and  persistent  irritation. 

Asthenopia  and  frontal  headache  due  to  accommo- 
dative or  muscular  strain.  To  lessen  the  irritability  of 
the  ciliary  muscle  preparatory  to  testing  errors  of  refrac- 
tion. 


5l6  PREVALENT    DISEASES    OF    THE    EYE. 

CONSTITUTIONAL  REMEDIES. 
Elix.  ferri  et  quiniae  et  strychniae  phosphat.     (Wyeth's.*) 

A  teaspoonful  three  times  a  day  for  adults;  for  chil- 
dren two-thirds  to  one-third  of  a  teaspoonful,  according 
to  age.  When  less  than  a  teaspoonful  is  prescribed,  it 
should  be  diluted  to  the  required  degree  with  elix.  sim- 
plex, so  that  the  quantity  to  be  given  shall  be  one  tea- 
spoonful. 

Phlyctenular  conjunctivitis  and  keratitis,  eczema  of 
the  lids,  and  eczematous  blepharitis  marginalis. 

Syr.    ferri    et    quiniae    et    strychniae    phosphat.    (Sharp    and 
Dohme's.*) 

Dose  and  indications  for  administration  the  same  as 
the  foregoing.     May  be  diluted  with  simple  syrup. 

Quiniae  sulphat.  in  three-grain  capsules. 

One  every  three  or  four  hours. 

Ulcer  and  abscess  of  the  cornea,  herpetic  keratitis, 
purulent  iritis,  and  threatening  panophthalmitis. 

Ext.  nucis  vom gr.  x 

Quiniae  sulphat gr.  xl-lxxx 

Ferri  carbonat.  (Vallet's) gr.  Ixxx. 

Ft.  capsules  xl. 

One  three  times  a  day. 

A  well-known  tonic  combination,  often  found  useful 
in  the  treatment  of  eye  diseases. 

Tinct.   nucis  vom 5j 

Tinct.  cinchonae  compos 5xj. 

Two  teaspoonfuls  three  times  a  day. 

*  These  particular  preparations  are  mentioned  because  they  con- 
tain a  considerably  larger  proportion  of  iron  and  qulnln  than  most 
of  the  preparations  which  are  sold  under  the  same  name. 


APPENDIX. 


517 


Another  excellent  tonic  combination,  especially  use- 
ful in  asthenopia  following  exhausting  diseases. 
Syr.  ferri  iodic!. 

Eight  to  twenty  drops,  in  a  wineglassful  of  water, 
three  times  a  day. 

Phlyctenular  conjunctivitis  and  keratitis,  accom- 
panied by  definite  signs  of  struma. 

Potassii  iodid.  (saturated  solution). 

In  increasing  doses. 

Rheumatic  and  syphilitic  inflammations  of  the  eye, 
especially  those  occurring  in  the  tertiary  stage  of 
syphilis,  uveitis,  sclero-keratitis,  scleritis,  paralysis  of 
the  ocular  muscles,  and  to  promote  the  absorption  of 
blood  in  the  vitreous  or  anterior  chamber,  and  of  cortical 
lens  substance  after  cataract  operations  or  injuries  of 
the  lens. 

Hydrarg.  biniodid gr.  j-ij 

Potassii  iodid gr.  x 

Aquae 5iv. 

A  teaspoonful  three  times  a  day,  after  meals. 

Syphilitic  aff^ections  of  the  iris,  ciliary  body,  choroid, 
retina,  and  optic  nerve ;  especially  those  occurring  during 
the  secondary  stage  of  the  disease;  also  in  glaucoma, 
retrobulbar  neuritis,  sympathetic  ophthalmitis,  etc. 
When  prompt  action  is  demanded,  its  administration 
may  be  supplemented  by  inunctions  of  mercurial  oint- 
ment, and  when  thought  desirable  the  proportion  of 
potassium  iodid  may  be  increased,  so  that  the  dose  pre- 
scribed shall  contain  five  to  ten  grains. 

Hydrarg.   biniodid gr.  j 

Potassii  iodid gr.  x-c 

Syr.   ferri  iodid 3ss 

Aquae 5  iijss. 


5l8  PREVALENT    DISEASES    OF    THE     EYE. 

A  teaspoonful,  in  a  vvineglassful  of  water,  three  times 
a  day,  after  meals. 

Interstitial  keratitis  and  other  chronic  syphilitic  af- 
fections. 

Hydrarg.  bichlorid gr.  j 

Tinct.  ferri  chlorid 5ss 

Aquae 5iijss. 

A  teaspoonful,  in  a  wineglassful  of  water,  three  times 
a  day,  after  meals. 

A  useful  substitute  for  the  foregoing,  especially  when 
the  iodides  are  not  well  borne. 

Potassii  iodid gr.  Ixiv-xcvj 

Syr.  ferri  iodid 5ss 

Aquae 5iijss. 

A  teaspoonful,  in  a  wineglassful  of  water,  three  times 
a  day,  after  meals. 
Interstitial  keratitis. 

Tablet  triturates  of  calomel  (gr.  ^-k). 

One  every  two  hours,  guarded  by  opium  if  found 
necessary,  and  supplemented  by  inunctions  of  mercurial 
ointment. 

When  prompt  mercurialization  is  called  for,  as  in 
severe  syphilitic  inflammation  of  the  iris,  choroid,  retina, 
optic  nerve,  etc.,  and  in  sympathetic  ophthalmitis. 

Sodii   salicylat.     (In  solution  or  in  capsules.) 

Ten  grains  everv  two  or  three  hours. 

Iritis,  cyclitis,  scleritis,  sclero-conjunctivitis,  espe- 
cially when  they  are  dependent  upon  a  rheumatic  dia- 
thesis, acute  glaucoma,  inflammation  of  the  uveal  coat 
due  to  traumatism,  whether  accidental  or  operative, 
and  in  much  larger  doses,  pushed  to  the  point  of 
toleration,  in  sympathetic  ophthalmitis. 


APPENDIX.  5IQ 

Strychniae  sulphat.     (In  solution  or  in  tablet  triturates.) 

In  increasing  doses,  to  be  given  directly  after  meals. 
Incipient  atrophy  of  the  optic  nerve  or  retina,  chronic 
retrobulbar  neuritis,  paralysis  of  the  ocular  muscles. 

Pilocarpin    hydrochlorat gr.  iv 

Aquae gss. 

Ten  drops  once  a  day,  the  dose  on  each  succeeding 
day  to  be  increased  by  two  or  three  drops,  accordino-  to 
the  effect  produced. 

Choroido-retinitis,  uveitis,  glaucoma,  detachment  of 
the  retina. 

Sodii    pyrophosphat 5 j 

Aquas 5xij. 

A  tablespoonful,  in  water,  every  two  or  three  hours. 
Acute  inflammation  of  the  lacrimal  sac,  cellulitis  of 
the  orbit,  abscess  of  the  lid. 

Natural  lithia  water. 

To  be  drunk  freely. 

Gouty  affections  of  the  eye — scleritis,  iritis,  retinitis, 
etc. 

"Compound  Calomel  Powder." 

(Frequently  mentioned  in  the  text.) 

Hydrarg.    chlorid.   mitis gr.  ij-iv 

Pulv.  scammonii gr.  ij 

Pulv.  rad.  rhei g'"-  ^j- 

Ft.  capsules  ij  (or  may  be  given  in  powder  form). 

The  two  capsules,  or  the  whole  powder,  to  be  given  at 
bedtime.  The  dose  may  often  be  repeated  with  advan- 
tage after  forty-eight  hours. 


520  PREVALENT    DISEASES    OF    THE    EYE. 

As  a  first  measure  in  the  treatment  of  phlyctenular 
kerato-conjunctivitis,  especially  when  there  is  attendant 
eczema  of  the  lids,  face,  etc.,  also  in  acute  glaucoma, 
iritis,  and  whenever  an  energetic  purgative  is  called  for. 

Tablet  triturates  of  aloin  (gr.  x^o~4)* 

One  to  be  taken  at  bedtime. 
Habitual  constipation. 


INDEX. 


Note. — The   bold-face   type   indicates  the  pages  on  which  the  subjects 
are  especially  considered. 


Abducens,  paralysis  of.      See    Pa- 
ralysis  of   external  rectus  muscle. 
Ablatio  retinae.      See  Retina,  detach- 
ment of. 
Abscess  and  ulcer  of  cornea,  207 
of    lacrimal    sac.       See    Dacryo- 
cystitis. 
of  orbit,  108 
prelacrimal,  137 
Accommodation,  426 
abnormal  power  of,  428 
anomahes  of,  425 
different  ways  in  which    may  be 

impaired,  427 

disturbance  of  normal  relationship 

between  convergence  and,  396 

in  hypermetropia,  396,  397,  400 

asthenopia  caused  by,  396 

convergent  squint  caused  by, 

397. 
in  myopia,  407,  408 

asthenopia  caused  by,  408 
divergent    squint    caused  by, 

408 
in  subnormal  accommodative 
power,  434,  435 
asthenopia       caused       by, 

435 
how  remedied,  436 
failure  of,  from  advancing  age,  427 
Helmholtz's  theory  of,  426 
mechanism  of,  426 
normal  relationship  between  con- 
vergence and,  396 
how  disturbed  in  hypermetropia, 
396 
in  induced  cycloplegia,  435 
in  myopia,  407,  408 
in  subnormal  accommodative 
power,  434,  435 
paralysis  of,  427.      See   also  Pa- 
ralysis of  ciliary  muscle. 
symptoms  which  indicate,  32 
progressive  decline  of,  427,  428 


Accommodation,  rapid  failure  of,  an 

early  symptom  of  glaucoma,  279 

spasm  of,  427.     See  also  Spasm 

of  ciliary  muscle. 
subnormal    power    of,    427.     See 
also   Subnormal  accommodative 
power. 
Accommodative  power,  subnormal. 
See      Subnormal      accommodative 
power. 
Acromegaly  in  etiology   of  hemian- 
opsia, 386 
Actual  cautery- in  corneal  ulcers,  214 
Adrenalin   in    operation   for   ptery- 
gium,  lOI 
in  recurrent    intraocular    hemor- 
rhage, 337 
in  treatment  of  strictures  of  nasal 
duct,  143 
Advancement  of  muscle  in  conver- 
gent squint,  457 
in  divergent  squint,  465 
in  exophoria,  472 
in  heterophoria,  471 
After-cataract.     See   Cataract,   cap- 
sular. 
Age,  influence  of,  in  development  of 
convergent    squint,  402,  439, 

448 
in  diseases  of  choroid  and  ret- 
ina, 339 
in  glaucoma,  276 
in  interstitial  keratitis,  223 
in  myopia,  407,  412 
upon  cataract,    298,   299,   301, 

313,  314,  318 
upon  hypermetropia,  398,  401 
upon  the  accommodation,  426, 

427,  428,  429  _ 
upon  the  cr\'Stalline  lens,  295,296 
Agents  for  exact  application  to  eye 

or  lids,  514,  515 
Albuminuric  retinitis.    See  Retinitis, 
albuminuric. 


521 


522 


INDEX. 


Alcohol,    methylic,    in    retrobulbar 

neuritis,  374 
Alcoholism  in  hyperemia  of  conjunc- 
tiva, 153 
in  retroljulbar  neuritis,  376 
Aloin  in  habitual  constipation,  520 
in  recurrent  hordeola,  69 
in  retinal  hemorrhage,  337 
Alternating  strabismus.    See  Squint, 

alternating. 
Alum  and  boracic  acid,  formula  for 
collyrium  of,  506 
after  enucleation  of  eye,  273, 

506 
in    blennorrhea    of    lacrimal 
sac,  148 
cr^-stal  in  trachoma,  181 
"  Amaurotic  cat's  eye. "     See  Retina, 

glioma  of. 
Amblyopia  exanopsia,  319,  449 
misuse  of  term,  449 
of  squinting  eye,  how  induced,  449 
toxic.     See  Optic  neuritis,   retro- 
bulbar, chronic. 
uremic,  351 
Ametropia,  394 
definition  of,  394 
varieties  of,  394 
Ammonium  chlorid  in  treatment  of 

stricture  of  nasal  duct,  149 
Amnion's,  von,  operation  for  short- 
ening lid,  93 
Anagnostakis-Hotz    operation      for 

entropion,  86 
Anatomy  of  cornea,  204 
of  cn-stalline  lens,  295,  296 
of  eyelids,  68 

of  iris  and  ciliary  body,  251 
of  lacrimal  apparatus,    118,   121, 

126,  137 
pathological,    of    glaucoma,    283, 
284 
of  interstitial  keratitis,  224,  225 
of  stenosis  of  nasal  duct,   125, 

137.  138 
of  trachomatous  conjuncti\'itis, 

175,  176,  177,  ijS,  180 
of  ulcerative  keratitis,  205,  206, 
207,  209,  210 
Anchyloblepharon,  480,  483 
Anemia,  acute,  thrombosis  of  retinal 
arteni-  in,  359 
pernicious,  retinitis  in,  352 
Anesthesia  from  cocain,  51,  510 
and  adrenalin,  loi,  143 
from  holocain,  511 
general,  in  enucleation  of  eye,  270 

in  tenotomy  in  children,  461 
of  cornea,  how  determined,  35 


Anesthesia  of  cornea,  in  glaucoma, 
277 
in  neuropathic  keratitis,  217 
Angiosclerosis,  291,  302 
Angle  alpha  in  hypermetropia,  453, 

454 
Anisometropia,  424 

a  factor  in  causation  of  strabis- 
mus, 424 
consequences  of,  424 
definition  of,  424 
difference  in  size  of  pupils  due  to, 

25 

exceptionally    a    blessing   in    dis- 
guise, 424 

treatment  of,  424,  425 
Anomalies,  muscular.     See  Muscu- 
lar anomalies  0}  the  eyes. 

of  accommodation,  425 

of  refraction,  388 

and  accommodation,  388 
etiological    importance  of,  389, 

390 

general  obser^'ations  upon  sig- 
nificance of,  388 

harm  which  results  from 
unskilful   correction  of,    T)2>?>, 

389 

prevalent  misconceptions  re- 
garding, 390,  391,  392 

special  skill    and    training    re- 
quired in  correction  of,  388 
Anterior  chamber, examination  of,  by 
oblique  illumination,  37,  500 

evelash  lodged  in,  503 

filtration  angle  of,  282 

alteration  of,  in  glaucoma, 
283,  284 

inspection  of,  35 

obliteration  of,  in  glaucoma,  278 

paracentesis  of,  215 

pus  in,  211,  215 

removal  of  foreign  bodies  from, 

503 
polar  cataract,  320 
staphyloma.     See  Staphyloma    of 

cornea. 
synechia.     See  Synechia,  anterior. 
Antisepsis  in  wounds  of  eye,  495,  501 
preparatory'    to   operations    upon 
eye,  327,  461,  511 
Antiseptic  agents,  50,  51,  511,  512 
Antitoxin,  diphtheria,  61 
Apothecaries,  a  reprehensible  habit 

of,  43 
Appendix,  505 

Application  of  carbolic  acid  to  eye. 
See  Carbolic  acid,  application  of. 

of  colly ria,  41,  42,  43,  44 


INDEX. 


523 


Application  of  ointments  to  eye  and 

lids,  45 
Aqueous  humor,  inspection  of,  35,  36 
lessened     transparency     of,     in 
iritis,  247 
Arcus  senilis,  235 

pathology  of,  235 
Argyll  Robertson  symptom,  27,  379 
Argyria  conjunctiva?,  193 
etiology  of,  193 
signs  of,  193 

treatment  of  no  avail  in,  193 
Argyrol,  51-  ^57  . 

in  dacryocystitis,  137 
in  purulent  conjunctivitis,  164 
Argvrosis.     See  A  rgyria  conjunctivce. 
Arlt's  operation  for  ectropion,  95 

tenotomy,  457,  465 
Arsenic  in  herpes  zoster  ophthalmi- 
cus, 266 
in   neuropathic  keratitis,  222 
in  retinitis  of  pernicious  anemia, 

353 
Artificial  eye,  241,  273,  506 
pupil,  238,  267,  325,  326 
Associated  ocular  paralyses,  446 
Asthenopia,  symptoms  characteristic 

of,  32  _ 
Astigmatism,  413 

according  to  the  rule,  415 

usually  located  in  cornea,  415 
acquired,  417 

advantages  and  disadvantages  of  a 
cycloplegic  in  determination  of, 
422,  423 
a  factor  in  the  causation  of  cata- 
ract, 303,  345 
of  glaucoma,  285,  345 
of  miliar}^  choroido-retinitis, 

343 
of  myopia,  406 
after  cataract  extraction,  417 
against  the  rule,  415 

special   significance   of,    285, 

415,  416,  417 
usually  located  in  lens,  415 
apparent     increase    of,  how    ex- 
plained, 416 
a  significant  amount  of,  not  incom- 
patible  with  normal  acuteness 
of  vision,  417 
asthenopia,  how  caused  by,  414 
compound,  415 
consequences  of,    285,    303,    343, 

345,  406,  418 
corneal,  415 
correction  of,  by  cylindrical  glasses, 

419,  420 
definition  of  term,  413 


Astigmatism,  increase  of,  416 

irregular,  237,  413 

latent,  414,  416 

explanation  of,  414 

how  rendered  manifest,  416 

lenticular,  415 

manifest,  416 

may  be  acquired,  417 

may  be  due  to  asymmetry  or  ob- 
liquity of  crystalline  lens,  413 

measurement  of,  421,  422 
by  skiascopy,  422 
with  lenses,  test-type,  and  astig- 
matic dial,  422 
with  ophthalmometer,  422 
with  ophthalmoscope,  421 

method   of  detecting   pronounced 
degrees  of,  417,  418 

mixed,  415 

nature   of    visual   disturbance  in, 

413'  414. 
often  inherited,  413 
often  mistaken  for  myopia,  415 
one  of  the   commonest  refractive 

anomalies,  413 
orientation  of,  416 
principal  meridians  in,  416 
regular,  413 
seat  of,  413 
simple,  415 
static,  414 

symptoms  of,  414,  415 
the  cornea  the  usual  seat  of,  413 
the  ophthalmometer  an   untrust- 
worthy means  of  measuring,  422 
treatment  of,  419 
usually  a  congenital  fault,  413 
varieties  of,  413,  415 
Astringents  and  antiseptics,  indica- 
tions for  employment  of,  40 
Atresia  of  canaliculi,  130 
of  lacrimal  puncta,  126 
Atrophy  of  conjunctiva,  176 
of  eyeball  from  glaucoma,  280 
from     penetrating    wounds     of 

globe,  495,  496 
from    purulent    panophthalmi- 
tis, 334 
of  lacrimal  gland,  124 
of  optic  nerve,  378 

inflammatory,  381 
non-inflammatory,  378 
of  retina,  in  retinitis  pigmentosa, 

355     ^ 
Atropin,  46 

and  boracic  acid  collyria,  507,  508 
follicular  conjunctivitis  from  pro- 
longed use  of,  48 
glaucoma  induced  by,  47,  288 


524 


INDEX. 


Atropin,     idiosyncrasies     displayed 
towards,  4§,  261 
indications  for  employment  of,  40, 

46 
persistent  effect  of,  47 
to  be  used  with  caution  in  serous 

iritis,  261 
weak  solutions  of,  in  incipient  cat- 
aract, 311 
Author's     crochet-pointed     strabis- 
mus hook,  458 
doctrine  of  subnormal  accommo- 
dative power,  433 
eye-bandage,  55 

lacrimal  probe  for  use  by  patients, 
149 
probes,  141 
measurements  of  nasal  ducts,  141 
needle-holder,  459 
series  of  cataract  extractions,  316 
supplementary  lacrimal  probe,  145 
theory  of  the  etiolog\'  of  post-hem- 
orrhagic  blindness,  359 
of  the  genesis  of  pter\'gium,  198 
views  on  the  amblyopia  of  squint- 
ing eyes,  449,  450,  451 
on  the  genesis  of  sympathetic 
ophthalmitis,  258,  259 
Auto-infection,  208 


Bacillus,  Klebs-Loffler,  170,  211 

Weeks,  156 
Bader's  scleral  fixation  forceps,  270, 

272 
Bandage,  Author's  eye,  55,  56 
Bandages,   eye,   indications  for  use 

of,  56 
Basham's  mixture,  351 
Belladonna  and  mercury,  ointment 

of,  514 
lotion  of,  512 
Bichlorid  of  mercury.     See  Mercury, 

hichlorid. 
Bifocal  lenses,  421,  430 
cemented,  430 
invisible,  430 
Blennorrhea  of  lacrimal  sac,  132 
Blepharitis  marginalis,  63,  389,  467 
etiology  of,  64,  65 
treatment  of,  65,  66 
Blepharo-adenitis,  63 
"Blind    spot,"    enlargement    of,    in 

choked  disc,  371 
Blindness,  monocular,  often  present 
without  knowledge  of  patient,  33 
Blisters  in  acquired  ptosis,  100 
in  paralysis  of  facial  nerve,  107 
of  sixth  nerve,  443 


Blisters  in  retrobulbar  neuritis,  375 
Bonnet,  operation  of  enucleation  of 

eye  devised  by,  269 
Boracic  acid,  after  removal  of  ptery- 
gium, 200 
conditions  in  which,  is  useful,  51 
formulae  for  collyria  of,  504 
in  asthenopia,  51 
in  corneal  ulcers,  212 
in     diphtheritic     conjunctivitis, 

172 
in  hyperemia  of  conjunctiva,  153 
in  keratomalacia,  216 
in   membranous   conjunctivitis, 

i6q 
in  mild  catarrhal  conjunctivitis, 

in    phlyctenular    conjunctivitis, 

190 
in  superficial  injuries  of  cornea, 

.485 
ointment  of,  157 
saturated  solution  of,  511 

conditions     in     which,    is 

useful,  5 1 1 
in  purulent   conjuncti\atis, 

163 
in  wounds  of  the  lids,  482 
use  of,  as  a  poultice,  53,  511 
Bowman's  membrane,  204 
never  regenerated,  203 
operation   for   fistula   of   lacrimal 
gland,  121 
for  ptosis,  102 

of  division  of  canaliculus,  140 
probes,  inadequate  size  of,  140 
Bull,  C.  S.,  266,  292 
Buller's  shield,  166 
Buphthalmos,  276 

characterized  by  general  enlarge- 
ment of  eyeball,  276 
etiolog}'  of,  276 
Burns  of  conjunctiva,  481,  482,  483 
entropion  from,  482 
symblepharon  from,  482 
treatment  of,  482,  483,  484 
of  cornea,  485 

consequences  of,  485 
leucoma  from,  485 
treatment  of,  485,  486 
of  lids,  48 1 

ectropion  from,  481 
from  gunpowder,  483 
treatment  of,  482,  483 
Thiersch  grafts  in,  483 

Calomel  purge,  value  of,  in  inflam- 
matory affections  of  the  eye,  61 


INDEX. 


525 


Canal  of  Schlcmm,  282 
Canaliculi,  atresia  of,  1 30 
etiology  of,  130 
treatment  of,  130 
Canaliculus,  division  of  lower,  128 
of  upper,  130 
foreign  bodies  in,  131,  448 
knife,  Weber's,  129 

modified,  129 
polypus  in,  131 
Capsular   cataract.       See    Cataract, 

capsular. 
Carbolic  acid,  application  of,  to  cor- 
neal ulcers,  51,  213,  214,  215, 

514 
in  treatment  of  hordeolum,  70, 

Caries  of  orbit,  ill 
treatment  of,  113 

hydrochloric  acid  in,  113 
resulting  from  stricture  of  nasal 
duct,  148 
Castor  oil  in  burns  of  the  eye,  54 
solution  of    atropin   in,  indica- 
tions for  use  of,  54 
Cataract,  297 

accommodative   strain    in  causa- 
tion of,  303,  344,  389 
amber-colored,  characteristics  of, 

301,309 

anterior  polar,  320.     See  also  Cat- 
aract, pyramidal. 

black,  301 

Brisseau's   discovery   of  true   na- 
ture of,  298 

capsular,  326 
diagnosis  of,  327 
etiology  of,  326 
treatment  of,  327 

couching  of,  314 

discission  of,  as  formicrly  practised, 

314 

as  now  performed,  314 
encountered  oftenest  in  the  aged, 

298 
erroneous  ideas  long  prevalent  as 

to  nature  of,  297 
extraction  of,  314,  315 

combined,  315 

linear,  319 

prognosis  in,  316 

simple,  315 

suction,  319 
extractions,  author's  series  of,  316 
Forster's  operation  in  immature, 

313 
general,  299 

acquisition  of  "second-sight"  a 
premonitory  symptom  of,  302 


Cataract,  general,  amblyopia  conse- 
cjuent  upon,  319 
capsular  opacitv  after  extraction 

of,  318 
conditions  which  point  to  prob- 
able existence  of,  307 
constitutional    disorders    which 
predispose  to  development  of, 
302 
determination    of    maturity    of, 

307,  308,  309 
diagnosis  of,  304,  305 
errors  in,  35,  305,  306 
help  afforded  by  a  mydriatic 
in,  304,  305 
by   oblique  illumination 

in,  304,  306 
by    ophthalmoscope    in, 
305 
nature   of  visual  impairment 

helpful  in,  300,  307 
subjective    symptoms    to    be 
considered  in,  306,  307 
differences  in  rapidity  of  devel- 
opment of,  301 
due    to    degeneration    of    lens 

fibers,  302 
etiology  of,  302,  303,  304 
normal  response  of  pupil  to  light 

in,  300 
ocular    diseases    which    predis- 
pose to,  303 
predisposition  to,  often  inheri- 
ted, 302 
prenatal    development  of,   303, 

304 
traumatic  lesions  which  tend  to 

production  of,  303 
treatment  of,  310-320 

atropin  in,  310 

only  operative,  of  avail,  310 

post -operative,  316 

prophylactic,  310 

when  immature,  313 

when  only  one  eye  is  involved, 

312,  3}3 
variations  in  color  of,  301 
varieties  of,  299 
in  detachment  of  retina,  363 
in  high  myopia,  342 
origin  of  name,  297,  298 
partial,  320 

definition  of,  320 
etiology  of,  320, 321,322,323,324 
varieties  of,  320 
posterior  polar,  322,  356 
etiologv-  of,  323,  324 
treatment  of,  325 
varieties  of,  323,  324 


526 


INDEX. 


Cataract,  pyramidal,  321,  322 
etiolog\'  of,  321,  322 
vision  in,  322 
ripeness  of,  307 

secondary.     See    Cataract,  capsu- 
lar. 
traumatic,  294,  299,  303,318,492, 

494,  498,  499 
varieties  of,  298,  299 
zonular,  324 

diagnosis  of,  325 
etiology-  of,  324 
impairment  of  vision  in,  325 
treatment  of,  326 
Catarrhal  conjunctivitis.     See  Con- 
junctivitis, catarrhal. 
Cathartic,    energetic,    value    of,    in 

inflammations  of  the  eye,  61 
Caustic  potash,  treatment  of  entro- 
pion of  lower  lid  with,  82 
Cauter\',  actual,  in  corneal  ulcers,  214 
Cellulitis  of  orbit,  108 
complications  in,  109 
diagnosis  of,  109 
etiolog}'  of,  108 
symptoms  of,  108 
treatment  of,  109 
Central  artery  of  retina,  embolism  of. 
See    Embolism     of    central 
artery  of  retina. 
thrombosis  of .    See  Thrombo- 
sis of  central  artery  of  retina. 
retinal  vein,   thrombosis   of.     See 
Thrombosis    of    central    retinal 
vein. 
Chalazion,  73 

clinical  history  of,  73,  74 
diagnosis  of,  73 
etiology  of,  73 
operation  for,  75 
treatment  of,  74 
Childhood,  glaucoma  in,  276 
Children,  examination  of  eyes  of,  57 
Chlorin  water  in  corneal  ulcers,  212, 

221,  507 
Choked  disc,  370 

commonly  caused  by  intracra- 
nial new-growths,  371 
consequences  of,  371 
etiolog}-  of,  367,  368,  371,  372 
ophthalmoscopic  picture  of,  369, 

370 
pathology  of,  368,  369 
prolonged  course  of,  371 
sight    often    insignificantly    im- 
paired in  early  stages  of,  371 
symptoms  of,  371 
treatment  of,  373 
usually  bilateral,  372 


Chorea,  390,  418 

Choroid  coat,  diseases  of,  340 

retina,  and  optic  nerve,  diseases 
of,  338 
etiolog}'  of,  339 
impairment    of   vision 

in.  338  _ 
prognosis  in,  339,  340 
recognition    of     exist- 
ence of,  without  the 
aid  of  the  ophthal- 
moscope, 338,  339 
symptoms      indicative 
'  of,  Zi?>,  339 
treatment    of,     to    be 
directed   to   the  un- 
derlying      systemic 
cause,  339 
sarcoma  of,  348 
tumors  of,  348 

commonlv  of  malignant  tvpe,. 

348 
treatment  of,  348 
Choroiditis,  340 

of  high  myopia,  342 

cataract  a  consequence  of,  342 
characteristics  of,  342 
detachment  of  retina  in,  342 
impairment  of  vision  in,  342 
treatment  of,  346 
plastic,  340 
etiology  of,  340 
of  traumatic  origin,  342 
etiology  of,  342 
serious  import  of,  343 
sympathetic     ophthalmitis 

from,  343 
treatment  of,  346 
varieties  of,  340 
purulent,  340.     See  also  Panoph- 
thalmitis, purulent. 
serous,      340.       See    also     Iritis, 

serous. 
syphilitic,  340 

impairment  of  ^^sion  in,  340 
iritis  frequently  associated  with, 

340 
loss  of  transparency  of  vitreous 

humor  in,  340 
occurs  in  inherited  syphilis,  340 
pathological  changes  in,  340,  341 
symptoms  of,  342 
treatment  of,  345 
Choroido-retinitis,  miliar}-,  343 

a  common  consequence  of  eye- 
strain, 343 
a  factor  in  causation  of  cataract 
and  glaucoma,  285,  303,  344,. 
345 


INDEX. 


527 


Choroido-retinitis,  miliary,  deserving 
of  more  consideration  than  is 
commonly  accorded  it,  343 
etiology  of,  343 

ophthalmoscopic  picture  of,  344 
"patchy  choroid"   a  result  of, 

344 
pathological  changes  in,  344 
symptoms  of,  344 
treatment  of,  347,  348 
Ciliary  body,  diseases  of,  268 
hernia  of,  494 
tumors  of,  269 
muscle,    insufficiency    of,  in  sub- 
normal accommodative  power, 

433'  435 
paralysis  of,  430 
spasm  of,  432 
Circumlental    space,    in    glaucoma, 

284 
Clonic  spasm  of  lids  from  reflex  den- 
tal irritation  and  from  phimosis, 
223 
Cocain    hydrochlorate,  formula    for 
solution  of,  510 
in  treatment  of  stricture  of  nasal 

duct,  143 
valuable  as  an  anesthetic,  but 
not  as  a   remedial    agent  per 
se,  51 
Colchicum,  244,  262 
"  Cold  "  as  a  factor  in  causation  of  ca- 
tarrhal conjunctivitis,!  56 
of  dacr)-oadenitis,  119 
of  dacryocystitis,  133 
of  neuropathic  keratitis,  219 
of  paralysis  of  sixth  nerve,  443 
of  retrobulbar  neuritis,  374 
Colly ria,  40-44,  46-52 

application  of,  41,  42,  43,  44 
contamination  of,  by  apothecaries, 

43 
formulas  for,  505-511 
precautions    necessary    in     using 

poisonous,  43 
rose-water  objectionable  in,  44 
sterilization  of,  501 
"Compound  calomel  powder,"  for- 
mula for,  519 
in  acute  dacryoadenitis,  120 
in  acute  dacr}-ocystitis,  136 
in  blepharitis,  66 
in  glaucoma,  289 
in  phlyctenular  conjunctivitis, 

192 
in  recurrent  hordeola,  71 
Concomitant  squint,  448.     See  also 

Squint,  concomitant. 
Condylomatous  iritis,  255 


Conical  cornea,  241 

galvano-cautery  in,  242 
marked  impairment  of  vision  in, 

241 
myopia  of  high  grade,  a  conse- 
quence of,  241 
symmetrical  aberration  in,  241 
treatment  of,  241 
Conjugate  ocular  paralyses,  446 
etiology  of,  446,  447 
pathology  of,  446,  447 
symptoms  of,  446,  447 
treatment  of,  447 
varieties  of,  446 
Conjunctiva,  diseases  of,  151,  467 
hyperemia  of,  152 
injuries  of,  481,  482,  483 
Conjunctivitis,  154 
catarrhal,  154 
acute,  155 

bacteriology  of,  156 
diagnosis  of,  155 
etiology  of,  156 
nearly  always  binocular,  155 
prognosis  in,  156 
treatment  of,  157 
chronic,  157 
etiology  of,  157 
treatment  of,  157 
croupous,  168 

character  of  membrane  in,  169 
etiology  of,  168 
symptoms  of,  169 
treatment  of,  169 
diagnostic  signs  and  symptoms  of, 

151 
diphtheritic,  169 

atypical  forms  of,  171 

bacteriology'  of,  170,  172 

character  of  membrane  in,  170 

consequences  of,  171 

entropion  from,  171 

infection,  modes  of,  in,  171 

symptoms  of,  170 

treatment  of,  172 
follicular,  173 

pathology  of,  173 

symptoms  of,  173 

treatment  of,  173 
gonorrheal,   158.     See    also    Con- 
junctivitis, purulent. 
lymphatica.     See    Conjunctivitis, 

phlyctenular. 
phlyctenular,    186 

associated    pathological    condi- 
tions in,  192 

catarrhal  type  of,  187 

consequences  of,  187 

diagnosis  of,  187 


528 


INDEX. 


Conjunctivitis,  phlyctenular,  etiology 
of,  1 88 

pathology  of,  i86 

symptoms  of,   i86 

treatment  of,  189 
purulent,  158 

bacteriology  of,  158,  162 

BuUer's  shield  in,  165 

consequences  of,  160 

etiology  of,  159 

prognosis  in,  160 

prophylaxis  in,  167 

symptoms  of,  158 

treatment  of,  161 
toxic,  48,  50,  192 

etiology  of,  193 

symptoms  of,  193 

treatment  of,  193 
trachomatous,  174 

consequences  of,  176 

entropion  from,  177 

etiology  of,  174,  178 

implication  of  cornea  in,  174, 177 

pannus  in,  development  of,  177 

pathology  of,  174,  176 

symptoms  of,  174 

treatment  of,  179 
mechanical,  181 
varieties  of,  154 
vernal,  183 

bulbar  type  of,  183 

palpebral  type  of,  184 

pathology  of,  184 

significance  of  name,  183 

symptoms  of,  185 

treatment  of,  185 

varieties  of,  183 
Consecutive  atrophy  of  optic  nerve. 

Constipation,  habitual,  aloin  useful 

in,  520 
Constitutional    remedies    useful    in 
diseases  of  the  eye,  39 
formulae  for,  516-520 
observations  upon,  57-62 
Contusions  of  eye,  491 

commoner  causes  of  severe,  493 
eyeball,  how^  protected  against, 

491 
injuries  that  may   result  from, 

491,  492,  493 
myopic  eyes  most  apt  to  suffer 

from,  407,  492 
rupture  of  eyeball  from,  491 
sympathetic  ophthalmitis  from, 

493 
traumatic  cataract  from,  492 
treatment  of,  493,  494 
why  so  seldom  disastrous,  491 


Convergence   center,   lesions  of,   in 

associated  ocular  paralyses,  446 
Convergent  concomitant  squint,  453 
Copper  citrate  in  trachomatous  con- 
junctivitis, 182 
sulphate  in  trachomatous  conjunc- 
tivitis, 180,  181,  515 
Cornea,  abscess  and  ulcer  of,  207 
bacteriology  of,  210 
carbolic  acid  in  treatment  of, 

213 
clinical  history  of,  207,  209 
diagnosis  of,  208 
etiology  of,  208,  210 
malignancy  of,  factors  which 

determine,  210 
pathology  of,  207,  210 
symptoms  of,  208 
treatment  of,  211,  221 
varieties  of,  211 
and  sclera,  diseases  of,  202 
anatomy  of,  204 
anesthesia  of,  in  glaucoma,  277 
in    neuropathic    keratitis,    217, 

218,  220 
method  of  determining,  35,  277 
conical.     See  Conical  cornea. 
diseases  of,  202 
dots  on,  in  uveitis,  252 
eczema  of,  186 

inflammation  of.     See  Keratitis. 
leucoma  of,  236 
lodgment  of  foreign  bodies  on,  487, 

488 
loss   of  transparency  of,  in  glau- 
coma, 277 
macula  of,  236 
massage  of,  231 
nebula  of,  236 
opacities  of,  235 
leucomatous,  236 
macular,  236 
nebular,  236 
opacity  of,  senile,  235 
penetrating  wounds  of,  494.     See 
also  Wounds  0}  eye,   pene- 
trating. 
anterior  synechia  from,  494 
impairment    of    vision   from, 

494 
sensibility  of,  how  determined,  277 
staphyloma   of.     See  Staphyloma 

of  cornea. 
superficial  injuries  of,  485 
tattooing  of,  238 
tumors  of,  242 
ulcer  of,  207 

dendritic,  211,  220 

herpetic,  211,  220 


INDEX. 


529 


Cornea,  ulcer  of,  hypopyon,  211 

"infected,"  210 

marginal,  or  ring,  211 

mycotic,  21 1 

neuropathic,  217,  218 

phlyctenular,  205 

post-malarial,  2:0 

progressive,  209 

regressive,  209 

serpent,  211 

simple,  210 
Crede's  prophylactic  measures,   167 
Croupous  conjunctivitis,  168 
Crystalline  lens,  anatomy  and  phys- 
iology of,  295 

an  epithelial  structure,  295 

changes  in,  from  advancing  age, 

296       .    . 
characteristics  of,  in  early  life, 

295 
development  6i  nucleus  of,  296 
diseases  of,  295 
dislocation  of.     See  Dislocation 

of  crystalline  lens. 
growth  of,  295 
nutrition  of,  297 
transparency    of,    impaired    by 
malnutrition,  297 
Curet,  chalazion,  75 

use  of,  in  corneal  abscess,  215 
in  corneal  ulcers,  214 
in  periostitis  of  orbit,  113 
Curettage,  113,  214 
Cyclitis,  268 
etiolog}'  of,  268 
impairment  of  vision  in,  268 
plastic,  268 

oftenest  due  to  syphilis,  268 
sympathetic  ophthalmitis  worst 

type  of,  268 
treatment  of,  269 
purulent,  268 
infection  in,  268 
treatment  of,  269 
serous,  268.    See  also  Iritis,  serous. 
symptoms  of,  268 
treatment  of,  269 
usually  associated  with  iritis,  268 
Cycloplegia,  post-diphtheritic,  431 
Cyst,  hydatid,  of  orbit,  114 

sebaceous,  of  lid.     See  Milium. 

of  orbit,  114 
tarsal.     See  Chalazion. 
water}',  of  lid.    See  Hydrocystoma. 


Dacryoadenitis,  119 
acute,  119 

diagnosis  of,  119 

34 


Dacr}'oadenitis,    acute,   etiology   of, 

119 
mistaken  for  cellulitis  of  orbit, 

119 
symptoms  of,  119 
treatment  of,  120 
chronic,  1 19 

symptoms  of,  120 
treatment  of,  120 
Dacr\'ocystitis,  131 
acute,  133 
chronic,  132 
etiology  of,  131 
in  new-born,  150 

prognosis  favorable  in,  150 
treatment  of,  150 
symptoms  of,  132 
treatment  of,  136 
usually   dependent  upon  stricture 
of  nasal  duct,  131 
Dacryoliths,  122 
in  canaliculi,  131 
treatment  of,  131 
Dacryops,  121 
etiolog\'  of,  121 
Graefe's  operation  for,  122 
treatment  of,  121 
Daylight,  inspection  of  eye  by,  34 
"Dead"  teeth,  222 
Dendritic  keratitis,  220 
Dental    irritation,     reflex,     keratitis 
and   paralysis   of   accommodation 
from,  222,  223 
Descending  optic  neuritis,   372 
Detachment  of  retina,  360.     See  also 

Retina,  detachment  of. 
Determination  of  acuteness  of  vision, 

of  corneal  sensibility,  35,  277 
of  intraocular  tension,  23 
of  visual  field,  29 
Diabetes,   248,   302,   318,   339,   349, 

372,  379.  382 
Diabetic     retinitis.     See     Retinitis, 

diabetic. 
Diagnosis,  helpful  questions   to   be 
asked  in  endeavoring  to  reach  a, 

importance  of  an  early,  in  eye  dis- 
eases, 40 
Diagnostic  significance  of  symptoms 
observed  in  ocular  inflammations. 

Diagnosticating  diseases  of  the  eye, 
difficulties  with  which  the  general 
practitioner  has  to  contend  in,  1 7 

Dionin,  52 

formula  for  collyrium  of,  509 
in  glaucoma,  52,  2S9 


530 


INDEX. 


Dionin  in  iritis,  52,  261 

in  keratitis,  52,  213 

in  opacities  of  the  cornea,  52 
Diphtheria,  169,  170,  171,  430,  445 

antitoxin,  61,  172 
Diphtheritic  conjunctivitis,  169 
Diplococcus  of  Sattler,  174 
Diplopia,  crossed,  444 

homonymous,  444 

in  concomitant  squint,  448,  449, 
450,  451,  453.  454.  464 

in  heterophoria,  467 

in  paralytic  squint,  439,  441,  443i 

444.  445 
monocular,  in  incipient  cataract, 

307 
of   sudden  onset,  significance  of, 
33 
Discharge  from  eye,   character  and 
amount  of,  diagnostic  value  of,  36 
Discission    of    cataract,    314.      See 
also    Cataract,    general,    treatment 

"/■ 

Diseases  of  the  eye,  value  of  constitu- 
tional remedies  in,  38 

Dislocation  of  cr\'stalline  lens,   327 
acquired,  328 

beneath  the  conjunctiva,  328 
congenital,  328 
consequences  of,  328,  332 
diagnosis  of,  330,  331 
effect  upon  vision  of,  328,  329 
etiolog}'  of,  328 
in  high  myopia,  328 
interesting  case  of,  329 
into    the    anterior    chamber, 

327.  331 
iridodonesis    a    symptom  of, 

331 
traumatic,  328,  332 
treatment  of,  331,  332 
varieties  of,  327,  328 
of  lacrimal  gland,  122 
Donders  on  the  etiology  of  conver- 
gent squint,  397,  453 
Duboisin,  48 

Dyspepsia,    induced    by   eye-strain, 
418 


Ectropion,  88,  481 
cicatricial,  89 
epiphora  a  common  symptom  of, 

88 
etiology  of,  88 

from  chronic  conjunctivitis,  91 
from  facial  paralysis,  88 
often  induced  by  lacrimal  disease, 


Ectropion,  organic,  89 

Arlt's  operation  for,  95 
commonly  of  traumatic  origin, 

89 
etiolog}'  of,  89 
operative  treatment  of,  95 
employment  of  Thiersch  and 
WoLfe  grafts  in,  97 
senile,  88 

treatment  of,  91,  92 
spasmodic,  88 

comparable  to  paraphimosis,  89 
etiology'  of,  88 
Snellen's  operation  for,  92 
treatment  of,  92 
varieties  of,  88 
Eczema  conjunctivce,  186 
of  eyelids,  71 
etiology  of,  71 
treatment  of,  71,  72 
Edema  of  conjunctiva  induced  by 
dionin,  52 
of  lids  in  purulent  conjunctivitis, 

163 
of  retina  in  miliary  choroido-reti- 
nitis,  344 
Electrolysis  in  treatment  of  lacrimal 

stricture,  149 
Electro-magnet,  Svi^eet's,  499 
Embolism  of  central  arterv  of  retina, 

357 

consequences  of,  357 
etiolog}'  of,  357 
ophthalmoscopic  picture  of, 

357 
thrombotic  obstruction  mis- 
taken for,  357 
treatment  of,  358 
Emmetropia,  393 
definition  of,  393 

vision  not  necessarily  acute  in,  393 
Entogenous  infection  of  eye  after  cat- 
aract extraction,  316 
Entropion,  80 

from    diphtheritic    conjunctivitis, 

171 
from  trachomatous  conjunctivitis, 

177,  182 
from  trauma,  482 
of  lower  lid,  82 

treatment  of,  82 

■with  caustic  potash,  82 
of  upper  lid,  operation  for,  84 
organic,  81 

etiolog}'  of,  81 

Green's  operation  for,  86 

Hotz's  operation  for,  86 

treatment  of,  81 
senile,  81 


INDEX. 


531 


Entropion,  spasmodic,  81 
etiology  of,  81 
treatment  of,  82 
varieties  of,  80 
Enucleation  of  eyeball,  269,  294 
after-treatment  of,  273 
Bader's  scleral  forceps  in,  270, 

272 
control  of  hemorrhage  in,  273 
general  anesthesia  required  in, 

270 
instruments  needed  in,  270 
objectionable  practices  in  con- 
nection with,  273 
steps  of  operation  of,  272 
whenpanophthalmitis  is  present, 
269,  334 
Epilation  forceps,  183 
Epiphora  a  characteristic  symptom 
of  disease  of  the  lacrimal  drain- 
age apparatus,  126 
of  long  standing,  significance  of,  32 
Episcleritis,  244 
diagnosis  of,  244 
etiology  of,  244 
pathology  of,  244 
symptoms  of,  244 
treatment  of,  245 
Epithelioma  of  lid,  79 
Ergot,  337 

Erysipelas,  facial,  a  cause  of  throm- 
bosis of  central  retinal  vein,  359 
dacryocystitis  mistaken  for,  133 
Eserin,  49 

and  boracic  acid  collyrium,   for- 
mula for,  508 
follicular  conjunctivitis  from  pro- 
longed use  of,  50 
in  ulcerative  keratitis,  213 
precautions  necessary  in  use  of,  49 
production   of  iritis   from   injudi- 
cious use  of,  49 
rules  for  employment  of,  in  glau- 
coma, 49 
value  of,  in  glaucoma,  288,  293 
Esophoria,  473 

detection  and  measurement  of,  469, 

470.  474 

etiology  of,  396,  473,  475 

state  of  refraction  to  be  determin- 
ed in  every  case  of,  474 

symptoms  of,  466,  467 

treatment  of,  470,  471,  474 
by  glasses,  474,  475 
by  operation,  475,  476,  477 
Euphthalmin  hydrochlorate,  47 
formula  for  collyrium  of,  510 
in  diagnosis  of  cataract,  305 
of  iritis,  247 


Eversion  of  lacrimal  puncta,  128 

of  lower  lid,  22 

of  upper  lid,  22 
Examination  of  eyes  of  unruly  chil- 
dren, 57 
Exanthematous  fevers,  139,  192,  208, 

408 
Excision  of  chalazion,  absurdity  of 
attempting,  75 

of  lacrimal  gland,  124,  149 
sac,  149 

of  orbital  growths,  116 
"Exciting  eye,"  256,  257 
Exophoria,  471 

detection  and  measurement  of,  469, 
470 

etiology  of,  407,  408,  438,  467,  468, 

471 
symptoms  of,  466,  467 
treatment  of,  470,  471,  472,  476, 

477 
by  glasses,  472 
by  operation,  472 
Exophthalmos  from  hypertrophy  of 
lacrimal  gland,  123 
from  ophthalmoplegia  totalis,  445 
from   tumors   of    lacrimal    gland, 

I25_ 

of  orbit,  114 
in  cellulitis  of  orbit,  108,  109 
in  periostitis  of  orbit,  1 1 1 
External  recti  muscles,  insufficiency 
of.     See  Esophoria. 
rectus   muscle,   paralysis  of.     See 
Paralysis     of     external     rectus 
muscle. 
Extraction   of   cataract.     See  Cata- 

ract,  general,  treatment  of. 
Eye,  ametropic,  394 
artificial,  273 

circulation  of  lymph  in,  281 
emmetropic,  393 
exciting,  256,  257 
infection   of,   316,   317,   319,   494, 

495.  497 

injuries  of,  480 

inspection  of,  by  daylight,  34 
by  oblique  illumination,  36 

speculum,  457 

squinting,  amblyopia  of,  449 

sympathizing,  257 
Eyeball,  contusions  of,  491 

foreign  bodies  in.  See  Wounds  of 
eye  complicated  by  lodgment  of 
foreign  bodies  within  ball. 

gunshot  wounds  of,  498 

penetrating  wounds  of,  494 

protrusion  of.  See  Exophthal- 
mos. 


53^ 


INDEX. 


Eyc-dropper,  right,  and  wrong,  way 
to  hold,  42 
suggestions  regarding  use  of,  41, 

42 
transference    of    infectious  mate- 
rial by,  41 
Eyelid,  epithelioma  of,  79 
eversion  of,  22 
malignant  tumors  of,  79 
sarcoma  of,  80 
warts  upon,  78 
Eyelids,  anatomy  of,  68 
diseases  of,  63 
injuries  of,  480 
Eye-strain  a  factor  in  causation  of 
blepharitis,  64,  389 
of  cataract,  303,  344,  389 
of  choroido-retinitis,  343,  389 
of  chronic  conjunctivitis,  157, 

389 
of  glaucoma,   285,   290,  344, 

389 
of  headache,  390 
of  indigestion,  390 
of  insomnia,  390 
of  nausea,  390 
of  neurasthenia,  390 
of  somnolency,  390 
of  styes,  69 

of  tinnitus  aurium,  390 
of  vertigo,  390 
constitutional    disorders    due    to, 

389 
etiological  importance  of,  389 
ocular  maladies   caused  by,    389, 

39° 
symptoms  indicative  of,  32 


Facial  erv'sipelas,  133,  359 

nerv-e,  paralysis  of.     See  Paralysis 
of  facial  nerve. 
Far-sightedness.     See    Hypermetro- 

pia. 
Fellow-eye  in  diphtheritic  conjunc- 
tivitis, 173 
in  glaucoma,  290 
in     purulent    conjunctivitis,    165, 

166 
in  sympathetic  ophthalmitis,  257 
Fevers,    exanthematous,    139,    192, 

208,  408 
Field   of   vision,    contraction   of,    in 
detachment  of  retina,  363 
in  embolism  of  retinal  arter\', 

357 
in  glaucoma,  279,  287,  291 
in  primar}'  atrophy  of  optic 

ner\-e,  379 


F"ield  of    vision,  contraction   of,    in 
retinitis  pigmentosa,  355 
determination  of,  29,  30 
in  hemianopsia,   383,   384,  385, 

386 
simple  method  of  measuring,  29 
Filtration  angle  of  anterior  chamber, 
283 
obstruction  of,  in  g.aucoma,  283, 
284 
Fistula,  lacrimal,  134,  148 

of  lacrimal  gland,  120 
Fixation,  binocular,  disinclination  to, 
observ^ed    in    some   cases    of 
squint,  456 
the  ideal  result  aimed  at  in  oper- 
ating for  squint,  450 
Fixing    eye,    determination    of,    in 

squint,  452 
Florence  flask  for  sterilizing  coUvria, 

504 
Fluidity  of  the  vitreous  humor,  334 
Follicular  conjunctivitis,  173 

induced  by  atropin,  48 

induced  by  eserin,  50 
Foreign  bodies  in  anterior  chamber, 

503 
in  iris,  500 
in  lens,  498 
in  orbit,  504 
in  vitreous  chamber,  500 
superficial  lodgment  of,  in  eve, 
486 
means  of  detecting  489 
misconceptions     of    pa- 
tient in  regard  to,  489 
occupations    which    pre- 
dispose to,  487 
symptoms    which    point 

to,  32,  489 
treatment  of,  490,  491 
within  the  eyeball.     See  Wouuds 
0}  eye  complicated  by  lodgment 
of  foreign  bodies  li-ithin  ball. 
Formulae  for  agents  for  exact  appli- 
cation to  eye  and  lids,  514,  515 
forcollyria,  505,506,  507,  508,  509, 

5io>  5V 
for  constitutional  remedies  useful 
in  eye  diseases,  516,  517,  518, 
519-  520 
for  lotions,  511,  512 
for  ointments,  513,  514 
Forster's  operation,  313,  325 
Fourth     nerve,     jiaralysis    of.     See 
Paralysis  of  superior  oblique  mus- 
cle. 
Fowler's   solution   in   herpes   zoster 
ophthalmicus,  266 


INDEX. 


533 


Fuchs  on  identity  of  herpes  corneae 
febrilis  and  keratitis  dendritica, 

221 

on  pathology  of  pinguecula,  195 
of  pter\-gium,  197 
of  vernal  conjunctivitis,  184 
Fulminating  glaucoma,  286 
Fungous  growth  in  dendritic  kera- 
titis, 211 
Fungus  hematodes  oculi.     Sec  Ret- 
ina, glioma  of. 


Galvanism  in  acquired  ptosis,  100 
in  retinitis  pigmentosa,  357 
of  little  value  in  primary  atrophy 
of  optic  nerve,  381 

Galva no-cautery,  149,  215 

Gasserian  ganglion,  20S 

Gifford's  use  of  sodium  salicylate  in 
sympathetic  ophthalmitis,  265 

Gland,      lacrimal.      See      Lacrimal 
gland. 

Glands  of  eyelid,  68 

Glasses,    action    of,    in    ametropia, 

392 

bifocal,  421,  430 

in  presbyopia,  429,  430 
in    subnormal     accommodative 
power,  436 

cylindrical,  419 

do  not  "  weaken  sight, "  391 

effect  of,  in  astigmatism,  419,  420 
in  hypermetropia,  396,  399,  40c, 

401,  402 
in  myopia,  406,  408,  410 

not  every  eye  needing  their  help 
makes  a  direct  appeal  for,  392 

not  given  solely  with  a  view  to  mak- 
ing vision  more  acute,  391 

not  to  be  regarded  as  a  dernier  res- 
sort,  391 

popular  misconceptions  regarding, 
390,  391,  392 

smoke-tinted,  55 

sphero-cylindrical,  419,  420 
Glaucoma,  274 

fulminating,  286 

hemorrhagic,  286 

inflammatory,  276 

clinical  history  of,  279,  280 
constitutional  disorders  predis- 
posing to  the  development  of, 

-'85 
diagnosis  of    277,  278,  279,  281 
duty  of  general  practitioners  in 

management  of,  287 
etiolog>'  of,  281,  282,  283,  285 
intermittent  character  of,  279 


Glaucoma,  inflammatory,  narrowing 
of  the  visual  field  in,  286 
ophthalmoscopic  picture  of,  278 
sympathetic      ophthalmitis 

caused  by,  280 
symptoms    of,    objective,    277, 
278 
subjective,  277 
treatment  of,  287,  289 

constitutional     remedies     in, 

289 
correction  of  refractive  errors 

in,  290 
dionin  in,  289 
eserin  in.  288 

iridectomy  the  sovereign  rem- 
edy in,  287,  289 
of  fellow-eye  in,  290 
varieties  of,  286 
malignant,  286,  289 
secondary,  293 
definition  of,  293 
etiology  of,  293,  294 
symptoms  of,  294 
treatment  of,  294 
simple,  291 

diagnosis  of,  291,  292 
etiology  of,  291 
symptom  of,  291 
treatment  of,  292 
iridectomy  in,  292 
non-operative,  293 
sympathectomy  in,  293 
Glioma  of  retina,  364 
Gonococcus,  158,  162 
Gonorrhea  a  cause  of  dacrj-oadenitis, 

119 
Gonorrheal  conjunctivitis.    See  Con- 
junctivitis, purulent. 
iritis,  248 

ophthalmia.     See    Conjunctivitis, 
purulent. 
Gout  in  etiology  of  dacryoadenitis, 
119 
of  eczema  of  lids,  71 
of  glaucoma,  285,  291,  293 
of  iritis,  248,  251,  266 
of  retinitis,  349 
of  retrobulbar  neuritis,  374 
of  scleritis,  242 
Gouty  affections  of  eye,  lithia  water 

in,  519 
Graduated  tenotomies,  no  room  for, 

476 
Graefe's,  von,  operation  for  dacry- 
ops,  122 
vertical  diplopia  test,  4-^4,  469 
Grandmont's,  de,  operation  for  pto- 
sis, 102 


534 


INDEX. 


Granular  conjunctivitis.     See  Cott- 
junctivitis,  trachomatous. 

lids.     See   Conjunctivitis,    tracho- 
matous. 
Green's  operation  for  entropion,  86 
"Ground-glass"  cornea,  223 
Gruening's  operation  for  ptosis,  102 
Gummata  in  lacrimal  sac  and  nasal 

duct,  139 
Gummatous  iritis,  255 
Gunshot-wounds  of  eye,  498 


Halsted's  use  of  silver  foil  as  a  sur- 
gical dressing,  96 

Head  and  Campbell's  investigation 
of  pathology  of  herpes  zoster,  259 

Headache  in  ametropia,  32,  390,  398 
in  astigmatism,  418 
in  choked  disc,  371 
in  latent  muscular  anomalies,  431, 

467. 
in  toxic  amblyopia,  375 
Helmholtz's  theory  of  accommoda- 
tion, 426 
Hemianopsia,  383 
binasal,  384 
bitemporal,  385 

etiology  of,  383,  386 
localizing  value  of,  387 
prognosis  in,  386 
symptoms  of,  383 
treatment  of,  387 
etiology  of,  383,  385 
explanation  of,  383 
homonymous  lateral,  385 

central  vision  retained  in,  385 
etiologv'  of,  385 
pathologv'  of,  385 
symptoms  of,  385,  386 
transient  type  of,  386 
treatment  of,  387 
without  localizing  value    386 
horizontal,  384 
symptoms  of,  383 
varieties  of,    383,  384 
Hemiopia.     See  Hemianopsia. 
Hemorrhage    into    vitreous  humor, 
336 
subconjunctival    193 
Hemorrhagic  glaucoma,  286 
Hernia  of  cilian,'  body,  494 
of  iris,  494 

of  lacrimal  gland.     See  Lacrimal 
gland,  dislocation  of. 
Herpes  corncre  febrilis,  220 
zoster  ophthalmicus,  218,  259 
etiolog)-  of,  218 
impairment  of  vision  from,  2 1 8 


Herpes    zoster    ophthalmicus,    iris 
often  involved  in,  218 
symptoms  of,  218 
treatment  of,  221 
Heterophoria,   466,   467,   469,   470, 
477.      See    also  Muscular   anom- 
alies of  the  eyes,  latent. 
Holden,  Ward,  378 
Holocain,    action   of,    in   promoting 
healing  of  corneal  ulcers,  213 
formuke  for  colly ria  of,  507,  511 
in  corneal  ulcers,  181,  212,  213 
indications  for  use  of,  507 
in  episcleritis,  245 
in  keratomalacia,  216 
in  neuropathic  keratitis,  221 
Homatropin  hydrobromate,  47 
formula  for  collyrium  of,  510 
in  diagnosis  of  cataract,  304,  305 
of  iritis,  247 
Hordeolum,  67 
etiology  of,  67,  69 
symptoms  of,  67 
treatment  of,  69,  70,  71 
abortive,  69 
Hot  water,  512 

in  interstitial  keratitis,  229 
in  iritis,  262 

in  purulent  conjunctivitis,  163 
Hotz's  operation  for  entropion,  86 
Hutchinson,  Jonathan,  223 

teeth,  227 
Hyoscyamin  hydrobromate,  48,  436 

formula  for  collyrium  of,  509 
Hyperemia,    diagnostic    significance 
of  the  different  tvpes  of  bulbar, 

35 

of  conjunctiva,  152 
acute,  153 
chronic,  153 
etiolog>'  of,  153 
treatment  of,  153 
Hypermetropia,  394 

absolute,  395 

axial,  397 

commonly  of  congenital  origin,  395 
.   consequences   of,    396,    398,    399, 
401, 402 

correction  of  convergent  squint  in, 
402 

curvature,  397 

definition  of,  395,  397 

disturbed  relation  of  accommoda- 
tion and  convergence  in,  396, 
402 

factors  which  influence  develop- 
ment of  squint  in,  397 

how  acquired,  397 

influence  of  glasses  in,  396, 399,402 


INDEX. 


535 


Hypermetropia,  manifest,  401 

most  prevalent  type  of  ametropia, 

395 
non-facultative,  395,  398 
not  a  pathological  condition,  397 
often  complicated  by  astigmatism, 

403_ 
often  inherited,  398 
presbyopia  influenced  by,  401 
relation  of  convergent  squint  to, 

397.  402 
rules  for  prescription  of  glasses  in, 

399,  400,  401,  402 
tension  of  accommodation  in,  395, 

396 
treatment  of,  399,  400,  401,  402, 

4p3_ 

varieties  of,  395,  397,  401 
Hyperopia.     See  Hypermetropia. 
Hyperphoria,  477 

definition  of,  477 

detection  and  measurement  of,  478 

etiology  of,  477 

ill  consequences  of,  477,  478 

treatment  of,  478,  479 
Hypertrophy  of  lacrimal  gland,  123 
Hypochyma,  298 
Hypopyon  in  iritis,  255 

ulcer  of  cornea,  211 


Ice-cloths,  41,  154,  512 

in  purulent  conjunctivitis,  163 
Iced  water,  41,  512 
Illumination,  oblique.     See  Oblique 

illumination. 
Imbalance,  muscular,  468 
Incised  wounds  of  cornea,  494 

of  lids,  482 
Incubation     period,     indefinite,     in 
sympathetic  ophthalmitis,  257 
in  purulent  conjunctivitis,  159 
Indigestion,  279 

induced  by  eye-strain,  390,  467 
Infection  of  eye,  after  cataract  ex- 
traction, 316,  317,  319 
from  penetrating  wounds,  494, 

495.  497 
Injuries  of  bulbar  conjunctiva,  483 
consequences  of,  483 
from  caustic  agents,  483 
symblepharon  from,  483 
treatment  of,  483,  484,  485 
of  cornea,  superficial,  485 
consequences  of,  485 
from  caustic  agents,  485 
treatment  of,  485,  486 

when  wound  is  infected,  486 
of  eye  and  its  appendages,  480 


Injuries  of  eyelids,  480 

anchyloblepharon     from,     480, 

482,  483 
ectropion  from,  481 
from  gunpowder,  483 
malposition    of     the      lacrimal 

puncta  from,  480 
symblepharon  from,  480,  482 
treatment  of,  482,  483 
Thiersch  grafts  in,  483 
Insomnia  induced  by  eye-strain,  390, 

418,  467 
Inspection  of  eye  by  daylight,  34 
Insufficiency  of  external  recti  mus- 
cles, 473.      See  also  Esophoria. 
of    internal    recti    muscles,    471. 
See  also  Exophoria. 
Internal  recti  muscles,  insufficiency 

of.     See  E.xophoria. 
Interstitial  keratitis.     See  Keratitis, 

interstitial. 
Intraocular  lymph-stream,  282 
tension,  determination  of,  23 
how  noted,  24 
Inunctions  of  mercurial  ointment,  58 
Inversion  of  lacrimal  puncta,  128 

of  lid,  80 
lodin,  tincture  of,  application  of,  to 
corneal  ulcers,  51 
ointment,  124 
Iridectomy,  161,  238,  240,  241,  266, 
267 
extraction  of  cataract  with,  315 
in  glaucoma,  49,  287,  289,  292,  294 
in  partial  cataract,  325 
in  zonular  cataract,  326 
preliminary  to  extraction  of  cata- 
ract, 313 
IridocycHtis,  256,  268 
Iridodialysis,  491 
Iridodonesis,  331 

Iris  and  cilian,'  Ijody,  diseases  of,  246 
diseases  of,  246 
hernia  of,  494 
wounds  of,  494,  495,  498 
Iritis,  246 

a  common  cause  of  blindness,  246 
character  of  vascular  injection  in, 

247 
consequences    of    neglected,    250, 

267 
diagnosis  of,  246 
diagnostic  value  of  mydriatic  in, 

247 
etiology'  of,  248 
excited  by  injudicious  use  of  eserin, 

49  ... 

general  management  of  patient  in, 

266 


53^ 


INDEX. 


Iritis,  gonorrheal,  248 
hypopyon  in,  255 
involvement  of  deeper  eye  struc- 
tures in,  250 
iridectomy  in,  266,  267 
myotics  contraindicated  in,  50 
neuropathic.     See    Iritis,    trophic 

nerve. 
of  herpes  zoster  ophthalmicus,  2 18, 

259 
oftenest  dependent  upon  syphilis, 

255 
plastic,  250,  253 

characteristics  of,  250 

chronic,  260 

etiology  of,  251 

iridectomy  in,  267 

treatment  of,  260,  261 

types  of  posterior  synechia  in, 

254 

varieties  of,  251 
purulent,  252 

etiology  of,  252 

treatment  of,  260,  265 
serious  consequences  of  failure  to 

recognize,  246 
serous  (uveitis),  252 

characteristics  of,  252 

disposition   to    increased    intra- 
ocular tension  in,  252 

etiology  of,  252 

marked  impairment  of  vision  in, 

253 
treatment  of,  264,  265,  266 
spongy,  259 
sympathetic,  256 

bacteria  probably  play  no  part 

in  etiology  of,  258 
character  of  posterior  synechia 

in,  258 
clinical  history  of,  257,  258 
consequences  of,  258 
etiology  of,  256,  258,  259 
"incubation  period"  indefinite 

in,  257 
malignancy  of,  258 
ophthalmitis     from     neglected, 

250 
probably  neuropathic  in  origin, 

258 
removal  of  exciting  eye  in,  264 
resemblance     of,    to     iritis     of 

herpes   zoster   ophthalmicus, 

259 

symptoms  of,  258 

treatment  of,  260,  264 
mercury  in,  264 
sodium  salicylate  in,  265 
symptoms  of,  246,  247 


Iritis,  syphilitic,  254 
condylomatosa,  255 
diagnosis  of,  255 
gummosa,  255 
met  with  in  inherited  svphilis, 

255 
occurs  as  a  prenatal  affection, 

255 
occurs    oftenest    in    secondary 

stage  of  disease,  253 
symptoms  of,  254 
treatment  of,  260,  262,  263,  264 
treatment  of,  260 
"trophic"  nerve,  248 

character   of   posterior  syne- 
chia in,  249,  254,  259 
characteristics  of,  249 
etiology  of,  248,  259 
formation    of    anterior   syne- 
chia in,  254 
herpes   zoster    ophthalmicus 

a  variety  of,  259 
sympathetic    ophthalmitis    a 

variety  of,  259 
varieties  of,  248,  250 
varieties  of,  250 
Iron  chlorid  in  interstitial  keratitis, 

230_ 

in  retinitis  albuminurica,   351 
iodid,  517 

in  blepharitis  of  strumous  origin, 

.    ^7 

in  interstitial  keratitis,  230 

in  periostitis  of  orbit,  112 

in    phlyctenular    conjunctivitis, 

191 
in  scleritis,  245 

in  strumous  affections  of  eye,  60 
Irritation,  sympathetic,  257 


Jackson,  Edward,  172,  423 
Jaeger's  test  types,  28 
Japanese  stove,  41 
Jequirity,  183 
Juvenile  cataract,  298 


Keratitis,  202 

bacteriology  of,  204 

consequences  of,  203 

dendritic,  220 

etiology  of,  203 

from  reflex  dental  irritation,  222 

herpetic,  220 

impairment  of  vision  from,  203 

interstitial,  223 

a  disease  of  childhood,  223 


INDEX. 


537 


Keratitis,  interstitial,  always  depen- 
dent upon  inherited  syphilis, 
223 
chronirity  a  marked  feature  of, 

225 
diagnostic  signs  of,  224 
etiolog)'  oi,  223 
ground-glass      appearance       of 

cornea  in,  223 
Hutchinson   teeth  often  associ- 
ated with,  227 
iritis  in  conjunction  with,  226 
marked  impairment  of  vision  in, 

226 
pathology  of,  224 
recurrent  attacks  of,  not  rare,  226 
symptoms  of,  223 
treatment  of,  227 
neuropathic,  216 
anesthesia  of  cornea  in,  217 
disturbance    of    metabolism    of 
cornea  a  prime  factor  in  caus- 
ation of,  217 
etiology  of,  217,  222 
gasserian  ganglion  in,  216 
milder  forms  of,  218 

anesthesia  of  cornea  in,  219 
clinical    characteristics    of, 

219 
etiology  of,  219 
malarial  fever  a  factor  in 

causation  of,  220 
ophthalmic  ganglion  in,  219 
symptoms  of,  219 
treatment  of,  221 
usually  unilateral,  220 
varieties  of   218 
ophthalmic  ganglion  in,  217 
treatment  of,  221 
varieties  of,  216 
pannitic,  231 

canthotomy  in,  233 
diagnosis  of,  233 
etiology  of.  231 
treatment  of,  233 
phlyctenular,  205 
etiolog}'  of,  188 

impairment  of  vision  from,  205 
symptoms  of,  205 
treatment  of,  i8g,  206 
post-malarial,  220 
suppurative,  204 
bacteriologv  of,  204 
etiology  of,  204 

factors  which  determine  tracta- 
bility  or  intractability  of,  204 
symptoms  of,  202 
"trophic    nerve."     See  Keratitis, 
neuropathic. 


Keratitis,  ulcerative,  207 

varieties  of,  207 
Keratoconus.     See  Conical  cornea. 
Keratomalacia,  215 

etiology  of,  215 

malignancy  of,  216 

night-blindness      a      premonitory 
symptom  of,  216 

symptoms  of,  216 

treatment  of,  216 
Kerato-scleritis,  242 
Klebs-Loflfler  bacillus,  170,  171,  211 
Knapp's  operation  for  anterior  staph- 
yloma, 241 

roller-forceps,  118 


Lacrimal  apparatus,  diseases  of,  1 18 
drainage  apparatus,  125 
duct.     See  Nasal  duct. 
fistula,  134,  148 
etiology  of,  134 
treatment  of,  148 
gland,  anatomy  of,  121 
atrophy  of,  124 
diseases  of,  119 
dislocation  of,  122 
excision  of,  149 
fistula  of,  120 
hypertrophy  of,  123 

exophthalmos  from,  123 
treatment  of,  124 
Velpeau's  operation  for,  124 
inflammation   of.     See  Dacryo- 

adenitis. 
tumors  of,  125 
symptoms  of,  125 
treatment  of,  125 
varieties  of,  125 
probe,  author's,  for  use  by  patient, 
149 
supplementar}',  145 
introduction  of,  144 
probes,  author's,  141 
puncta,  atresia  of,  126 
etiolog}'  of,  127 
treatment  of,  127 
eversion  of,  128 
inversion  of,  128 
malpositions  of,  128 
treatment  of,  128 
sac,    abscess   of.     See   Dacryocys- 
titis. 
blennorrhea  of,  132 
etiology  of,  132 
symptoms  of,  132 
destruction  of,  149 
excision  of,  149 
gummata  of,  139 


538 


INDEX. 


Lacrimal  sac,  inflammation  of,  132. 
See  also  Dacryocystitis. 
priman'  inflammation  of,  131 
stricture.     See  Stricture  of  nasal 
duct. 
Lamellar    cataract.     See    Cataract, 

zonular. 
Latent  muscular  anomalies,  466 
Lateral   illumination.     See    Oblique 

illumination. 
Lead    acetate,    opacities    of    cornea 

from,  237 
Leber,  222 

Leeches  in  acute  dacryoadenitis,  120 
Lens,    crystalline.     See    Crystalline 
lens. 
dislocation  of.     See  Dislocation 

of  crystalline  lens. 
foreign  bodies  in,  498 
"trituration"  of,  313 
wounds  of,  303,  494,  498 
Lenses,  bifocal,  430 
cylindrical,  419 
spherical,  390 
types  of,  390 
Leucocythemic  retinitis,  352 
Leucoma,  187,  236 
adherens,  236 
with  anterior  synechia,  236 
Leucomata,  236 

Light  not  the  reprehensible  thing  it 
was  once  supposed  to  be,  54 
perception,  definition  of,  28 
protection  of  inflamed  eyes  from 
undue  exposure  to,  54 
Lithia  water,  519 

Local  remedies  useful  in  diseases  of 
the  eye,  39 
formulae   for,    505-515 
observations  upon,  39-57 
Locomotor  ataxia,  441 
Lotion  of  belladonna,  formula  for, 

in  iritis,  262 
"of  opium  and  boracic  acid, "  for- 
mula for,  512 
in  cellulitis  of  orbit,  109 
in  corneal  ulcers,  213 
in  dacr\'ocystitis,  136 
in  glaucoma,  288,  294 
in  iritis,  262 
in  miliar}' choroido-retinitis, 

348,  433 
in  myopia,  346,  412 
in  panophthalmitis,  334 
in  scleritis,  245 
in  traumatic  lesions  of  eye, 

346,  466,  493,  496,  502 
"Lotions,"  formula;  for,  511,  512 


Lower  lid,  ectropion  of,  induced  by 
lacrimal  disease,  89 
operation  for  entropion  of,  82 
Luxation  of  lens.     See  Dislocation 

of  crystalline  lens. 
Lymph-spaces  of  eye,  282,  283 
Lymph-stream  of  eye,  281,  282,  283 
increase  of,  in  glaucoma,  284 


Macula  lutea,  344 

Maculae  of  cornea,  236 

Macular  region,  407 

Maddox-rod,  469,  470,  478 

Magnet,  Sweet's,  499 

Malarial  fever,  keratitis  induced  by, 

220 
"Malignant"  glaucoma,  286,  289 
tumors  of  choroid,  348 

of  ciliary  body,  269 

of  lacrimal  gland,  125 

of  lid,  79 

of  orbit,  114 

of  retina,  364 
Maturity  of  cataract,  308,  309 
Meibomian  glands,  68 
Membranous  conjunctivitis,  168 
Meningitis  basilar,  372 

in  causation  of  optic  neuritis,  371, 

372 
tuberculous,  371 
Mercurial  inunctions,  263,  264,  353 
Mercur\%   administration  of,  in  eye 
diseases,  58 
bichlorid,  50,  51 

addition  of  sodium  chlorid   to 

collyria  of,  51 
as  nasal  spray  in  treatment  of 

stricture  of  nasal  duct,  148 
formula  for  collyrium  of,  with 

sodii  chlorid,  506 
formulae  for   solutions  of,   511, 

512 
in  blennorrhea  of  lacrimal  sac, 

in  croupous  conjunctivitis,  169 
in    diphtheritic    conjunctivitis, 

172 
in  folHcular  conjunctivitis,  173 
in  penetrating  wounds  of  eyeball, 

495 
in  stricture  of  nasal  duct,  148 
internally,  with  tincture  iron,  in 
interstitial  keratitis,  230,  518 
in  vernal  conjunctivitis,    185 
in  wounds  of  eyelids,  482 
contraindicated     in     suppuration 
and   ulceration  of    cornea,    58, 
212 


INDEX. 


539 


Mercury  in  acquired  ptosis,  loo 
in  choroiditis,  345 
in  choroido-retinitis,  310 
in  chronic  dacryoadenitis,  120 
in  cycHtis,  269 
indications  for  administration  of, 

517.  518 
in  diseases  of  the  eye,  57 
in  herpes  zoster  ophthalmicus,  263 
in  interstitial  keratitis,  229,  230 
in  iritis,  262,  263 
in  optic  neuritis,  373 
in  paralysis  of  third  ner\'e,  446 
in  periostitis  of  orbit,  112 
in  retrobulbar  optic  neuritis,  375 
in  secondary  glaucoma,  294 
in  sympathetic  ophthalmitis,  264 
in  syphilitic  orbital  growths,  117 

retinitis,  353 

tarsitis,  80 
yellow  oxid,  formula;  for  ointments 

of,  513 
in  blepharitis,  54,  65 
in  chalazion,  74 
in  corneal  opacities,  238 

ulcers,  212 
in  eczema  of  lids,  71,  190 
in  hordeolum,  69,  70 
in  phlyctenular  conjunctivitis, 

189' 
in  vernal  conjunctivitis,  185 
of    no    value    in    interstitial 
keratitis,  229 
Metallic  foreign  bodies,  497,  502,  504 
Miliarv'  choroido-retinitis,  303,  343 
Mihum,  77 

treatment  of,  77 
Moist  heat,  method  of  applying,  to 

eye,  41 
Monocular     blindness,     individuals 
not  rarely  unaware  of  existence  of, 

33 
Mucocele,  132 
Mumps,  119 
Murdoch's  eye-speculum,  457,  458 

protective  shield,  317 
Muscae  volitantes,  335 

more  numerous  and   conspicu- 
ous in  ametropic  eyes,  336 
popular    misconceptions    as    to 

significance  of,  335 
present  in  all  eyes,  335 
Muscle-balance,    determination    of, 
469 
Maddox-rod  in,  469 
Schild's  pin-hole  light  in,  470 
in    correction    of    hypermetropia, 
401 
of  myopia,  410 


Muscle-balance  in  subnormal  accom- 
modative power,  434,  435,  436 
Muscular   anomalies    of    the    eyes, 
438 
actual,  467,  468 
apparent,  467,  468 
dependent     upon     refractive 

errors,  438 
etiology  of,  438 
latent,  438,  439,  466 

asthenopia,  how  caused  by, 

439-  467 

consequences  of,  439,  466, 
467 

contradictory  views  regard- 
ing etiology  of,  467,  468 

correction  of,  470,  471 
by  glasses,  470,  471 
by    operation,  470,  471, 

476,  477 
determination  of,  469,  470 
etiology  of,  467,  468 
heterophoria  a  synonym  of, 

466 
influence       of       refractive 

errors  upon,  467,  468 
multiple     Maddox-rod  .  in 

measurement  of,  469 
ocular   disturbances    from, 

467 
Schild's    pin-hole    light    in 

measurement  of,  470,  478 
treatment  of,  470,  471 
varieties  of,  467,  468 
whether  apparent  or  actual, 

how  determined,  468 
manifest,  438,  439,  440 

comprise  all  the  varieties  of 

squint,  438 
not  in  themselves  provoca- 
tive of  asthenopia,  439 
oftenest   due   to   refractive 

errors,  438,  439 
only      exceptionally      due 

solely  to  muscular  faults, 

438-  439 
the  deformity  and  rapidly 
developing  amblyopia  of 
misdirected  eye  most  seri- 
ous consequences  of,  439 
treatment  of.     See  Squint, 

treatment  of. 
when   of   paralytic   origin, 
develop  suddenly,  439 
of  congenital  origin,  438 
of  paralytic  origin,  438 
varieties  of,  438,  466 
imbalance,  468" 
Mycotic  ulcer  of  cornea,  211 


540 


INDEX. 


Mydriasis,  accidentally  induced,  431 
conditions  which  give  rise  to,  26 
disadvantages    of,    in    measuring 

refractive  errors,  422 
from    application    of    belladonna 

plaster,  431 
from  reflex  dental  irritation,  223 
in  o])hthalmoplegia  interna,  445 
in    paralysis    of    accommodation, 

431 

of  oculomotorius,  445 
Mydriatic,    value    of     transient,    in 
searching  for  pathological  changes 
in  eye,  37 
Mydriatics,    indiscriminate    use   of, 
reprehensible  in  advanced  life,  285 
Myopia,  403 

a  pathological  condition,  403 
apparent,   from   spasm  of  ciliary 

muscle,  432 
asthenopia  in,  408,  409 
astigmatism    a    potent    factor    in 

causation  of,  405,  406,  410 
axial,  404,  405 
cataract  in,  407 

caused  by  conical  cornea,  241,  405 
choroido-retinitis  in,  407 
curvature,  404 
definition  of,  403,  404 
detachment  of  retina  in,  407 
development  of  divergent   sfjuint 
in,  407,  408 

of  posterior  staphyloma  in,  404 
diagnosis  of,  409 

disturbed  relation  of  accommoda- 
tion and  convergence  in,  407 
etiology    of,   403,    404,    405,    406, 

408 
exceptionally    a    consequence    of 

systemic  disease,  408 
exophoria  in,  407,  408 
factors  which  influence  selection 

of  glasses  in,  410,  411,  412 
glasses    a    therapeutic    agent    of 

great  value  in,  411 
influence  of  age  upon  progress  of, 

407,  409 
influence  of  glasses  in,  410,  411, 

412 
muscae  volitantes  common  in,  409 
not  excluded  by  ability  to  read  at 

usual  distance,  t,3 
pathology  of,  404,  405,  406,  407 
predisposition  to,  often  inherited, 

403.  405 
removal  of  crystalline  lens  in  high, 

413 
symptoms  of,  409 
tenotomy  in,  413 


Myopia,  treatment  of,  409,  410,  41  r, 
412,  413 
usually  an  acquired  fault,  403 
Myopic  eyes  liable  to  injury  from 
trivial  traumatisms,  407,  492 
glasses,  410 
Myosis,  conditions  which  may  give 
rise  to,  26 
in  spinal  disease,  379 
Myotics,  action  of,  in  glaucoma,  48 
rules  for  employment  of,  49 


Nasal    disease,    etiological    impor- 
tance of,  in  causation  of  lacrimal 
stricture,  135,  138,  139 
duct,  anatomy  of,  137 

author's  measurements  of,  141 
stricture  of,  137 
Nausea  induced  by  eye-strain,  390, 

418,  467 
Near-sightedness.     See  Myopia. 
Nebula;  of  cornea,  236 
Necrosis  of  cornea,  109,  115,  x6o,  215 

of  orbital  walls,  ill 
Needle  for  removal  of  foreign  bodies, 
490 
operation    for   capsular    cataract, 

327 
for  juvenile  cataract,  314 
Nephritis    in     causation     of    optic 
neuritis,  372 
of  retinitis,  349 
Neurasthenia  induced  by  eye-strain, 

390,  418,  467 
Neuritis,  optic.     See  Optic  neuritis. 
Neuroepithelioma.     See  Retina,  gli- 
oma of. 
Neuropathic       iritis.       See       Iritis, 
^''trophic"  nerve. 
keratitis,  216 

milder  forms  of,  218 
origin    of    sympathetic    ophthal- 
mitis, 258 
Neuro-retinilis,  370 
Night-blindness    in    keratomalacia, 
216 
in  retinitis  pigmentosa,  355 
Nitrite  of  amyl  in  embolism  of  cen- 
tral retinal  artery,  358 
in  quinin  blindness,  378 
Nitroglycerin    in  quinin    blindness, 

Non-magnetic  foreign  bodies,  502 
Normal  salt-solution,  51,  505 
Notched  and  pegged  teeth,  227 
Noyes,  H.  D.,  and  E.  Williams,  first 
to  use  large  lacrimal  probes,  140 


INDEX. 


541 


Nystagmus,  447 
acquired,  447 
commonly    of    congenital    origin, 

447 
etiology  of,  447 
miner's,  447,  448 
treatment  of,  447,  448 


Oblique  illumination,  19,  36,  304, 
500 
information  afforded  by,  36 
Ocular  muscles,  440, 442 
anatomy  of,  440 
associated  movements  of,  446 

paralyses  of,  446 
insufficiency    of.      See    Muscu- 
lar anomalies,  latent. 
latent  anomalies  of,  446 
manifest  anomalies  of,  440 
nerves  distributed  to,  440 
operations  upon,  457,  458 
paralysis  of  441,  442.     See  also 
Squint,  paralytic. 
paralyses,    conjugate.     See    Con- 
jugate ocular  paralyses. 
Oculomotorius,    paralysis  of.       See 

Paralysis  0}  oculomotorius. 
Ointments,  application  of,  to  eye  and 
to  lids,  45 
forniulas  for,  513,  514 
indications  for  use  of,  53 
"O'd-sight,"  297 

Old-sightedness.     See  Presbyopia. 
Opacities  of  cornea,  235 

dionin  in  treatment  of,  238 
etiology  of,  235,  236 
from  lead  acetate,  237 
how  distinguished  from  lenticu- 
lar opacities,  238 
impairment  of  vision  from,  236 
iridectomy  for,  238 
tattooing  of,  239 
treatment  of,  238 
varieties  of,  236 
of  lens.     See  Cataract. 
of  vitreous  humor,  334 
secondary  capsular,  326 
Ophthalmia,     granular.     See     Con- 
junctivitis, trachomatous. 
neonatorum,  159,  161,  163 
purulent.         See     Conjunctivitis, 

purulent. 
sympathetic.     See   Iritis,    sympa- 
thetic. 
Ophthalmic  ganglion,  208 
Ophthalmitis,  sympathetic,  256.  See 
also  Iritis,  sympathetic. 


Ophthalmoplegia  externa,  445 

necessarily    of    nuclear    origin, 

445 
interna,  445.     See  also  Paralysis 
of  ciliary  muscle. 
oftenest  dependent  upon  diph- 
theria, 445 
totahs,  445 

characteristic  picture  of,  444, 445 
exophthalmos  a  symptom  of,  445 
Ophthalmoscope,    diagnosis    of    gli- 
oma of  retina  without  aid  of,  364 
ear  or  throat  mirror  as  substitute 

for,  305 
in  diagnosis  of  cataract,  305 
in  hands  of  general   practitioner 
rarely  trustworthy  aid  to  diag- 
nosis, 19 
Opium  and  morphin  in  diseases  of 
eye,  60 
as  a  local  remedy  in  diseases  of  the 

eye,  53 
lotion  of,  formula  for,  512 
mode  of  application  of,  53 
Optic  nerve,  atrophy  of,  378 
consecutive,  381 
diagnosis  of,  381 
etiology  of,  381 
ophthalmoscopic  picture  of, 

381,  382 
prognosis  in,  382 
symptoms  of,  381 
treatment  of,  382 
primar}-,  378 

Arg}-ll-Robertson  symptom 

in>  379 
behavior  of  pupil  in,  379 
etiology  of,  378 
hereditary  form  of,  379 
often   an  early  symptom  of 

tabes,  380 
ophthalmoscopic  picture  of, 

379.  380 
symptoms  of,  379 
treatment  of,  381 
unfavorable    prognosis    in, 

379.  381 
varieties  of,  378 
diseases  of,  367 

inflammation     of.     See     Optic 
neuritis. 
neuritis,  367 
descending,  372 
etiology  of,  372 
ophthalmoscopic    picture    of, 

368,  369,  372 
treatment  of,  373 
etiology  of,  367,  368 
intraocular.     See   Choked  disc. 


542 


INDEX. 


Optic  neuritis,  ophthalmoscopic  pict- 
ure of,  369 
orbital.     See  Optic  neuritis,  re- 
trobulbar. 
patholog)'  of,  367,  368,  369 
retrobulbar,  374 
acute,  374 

etiologA'  of,  374 
impairment    of    vision    in, 

374 
pathology  of,  374 
prognosis  in,  375 
symptoms  of,  374 
treatment  of,  375 
chronic,  375 

etiology  of,  375,  376 
more   common    in    males, 

375 
ophthalmoscopic     changes 

in-  376 
patholog}-  of,  375 
prognosis  in,  377 
symptoms  of,  375,  376 
treatment  of,  377 
varieties  of,  367,  368 
Orbicularis  muscle,  anatomy  of,  92 
Orbit,  abscess  of,  108 
benign  tumors  of,  114 
cellulitis  of,  108 
diseases  of,  107 
exenteration  of,  116 
mahgnant  tumors  of,  114 
sarcoma  of,  115 
tumors  of,  113 
Orbital  optic   neuritis.      See   Optic 
neuritis,  retrobulbar. 
walls,  periostitis  of,  1 1 1 
Orthophoria,  434 
Orthophoric  condition,  468 
muscle-balance,  434 


"Pain-reactiox"  test,  500 
Palsy.     See  Paralysis. 
Panas's  operation  for  ptosis,  104 
Pannitic  keratitis,  231 
Pannus,  174,  177,  182,  231 
diagnosis  of,  233 
etiology  of,  231 
treatment  of,  233 
Panophthalmitis,  purulent,  240,  268, 
269,  333 
consequences  of,  334 
course  of,  333 
etiolog)'  of,  333 
symptoms  of,  333,  334 
treatment  of,  334 
Papillitis.     See  Choked  disc. 


Paracentesis  of  anterior  chamber,  215 
Paralyses,    conjugate    ocular.      See 

Conjugate  ocular  paralyses. 
Paralysis    of    accom.modation.     See 
Paralysis  oj  ciliary  muscle. 
and  mydriasis  from  reflex  dental 
irritation,  223 
of  cilian.'  muscle,  430 
etiolog}'  of,  430,  431 
from    application    of     bella- 
donna plaster,  431 
from  reflex  dental  irritation, 

223 
often  accompanied  by  mydri- 
asis, 431 
prognosis    usually    favorable 

in,  431 
symptoms  of,  431 
treatment  of,  432 
vision,  how  impaired  in,  431 
of  external  rectus  muscle,  442 

commonest  of  ocular  pal- 
sies, 442 
etiology  cf,  443 
pathology  of,  443 
prognosis  favorable  in,  443 
symptoms  of,  443 
treatment  of,  443 
usually    of    orbital    origin, 

443 
of  facial  nerve,  105 

epiphora  from,  105 

etiolog}-  of,  106 

keratitis  in,  105 

symptoms  of,  105 

treatment  of,  106 
of  fourth  nerve,  444 
of  oculomotorius,  444 

etiologv'  of,  444,  445,  446 

one  of  the  commonest  ocular 
palsies,  444 

prognosis  in,  446 

ptosis  a   usual   symptom  of, 

445 
symptoms  of,  445 
treatment  of,  446 
varieties  of,  445 
of  sixth  nerve.     See  Paralysis  of 

exleYnal  rectus  muscle. 
of  superior  oblique   muscle,    444 
diagnosis  of,  444 
etiolog}'  of,  444 
symptoms  of,  444 
treatment  of,  444 
of  third  nerve,  444 
Paralytic     squint,     440.     See     also 

Squint,  paralytic. 
Parenchymatous  keratitis.    See  Ker- 
atitis, interstitial. 


INDEX. 


543 


Penetrating  wounds  of  eye,  494. 
See  also  Woimds  of  eye,  penetrat- 

Pepsin,  essence  of,  administered  in 
conjunction  with  potassium  iodid 
and  the  salicylates,  to  prevent 
gastric  irritation,  59 

Pericorneal  injection,  significance  of, 

35 
Perimeter,  standard,  30 
Periostitis  of  orbital  walls,  1 1 1 
consequences  of,  1 1 1 
etiology  of,  iii 
symptoms  of,  11 1 
treatment  of,  112 
Permanganate   of   potash   in    diph- 
theritic conjunctivitis,  172 
Pernicious  anemia,  retinitis  in,  352 
Persistent  pupillary  membrane,  320 
Phimosis,  spasm  of  orbicularis  pal- 
pebrarum from,  223 
Phlyctenular      conjunctivitis.      See 
Conjunctivitis,  phlyctenular. 
keratitis.     See  Keratitis,  phlycten- 
ular. 
Phosphates    of    iron,     quinin    and 
strychnin,  516 
in    blepharitis    marginalis, 

in  phlyctenular  conjunctiv- 
itis, 191 
in  recurrent  hordeola,  71 
value  of,  in  diseases  of  the  eve, 
60 
Photophobia,    not    a    symptom    of 

retinitis  or  neuritis,  32 
Phthisis  bulbi,  496 
Physiological  salt  solution,  5 1 
Pigmentary     degeneration     of     the 
retina,     354.     See    also    Retinitis 
pigmentosa. 
Pilocarpin    hydrochlorate,     formula 
for  collyrium  of,  509 
in  detachment  of  retina,  363 
in  iritis,  262 
in  optic  neuritis,  373 
in  serous  iritis,  265 
internal  administration  of,  61,  265, 

519 
Pinguecula,  194 

diagnosis  of,  195 

etiology  of,  195 

origin  of  name,  195 

pathology  of,  195 

treatment  of,  195 
"Pinkeye,"  156 

Pituitary  body,  enlargement  of,  386 
Plastic  cyclitis.     See  Cyclitis,  plastic. 

iritis.     See  Iritis,  plastic. 


Pneumococcus  in  catarrhal  conjunc- 
tivitis, 156 
in  suppurative  keratitis,  204,  211 
Polyopia,    monocular,    in    incipient 

cataract,  307 
Polypus  in  canaliculus,  131 
Posterior  polar  cataract,  322 
staphyloma,  404,  406,  408 
synechia.       See    Synechia,    poste- 
rior. 
Post-hemorrhagic     blindness,    etiol- 
ogy of,  359 
Post-malarial  keratitis,  220 
Post-neuritic  atrophy  of  optic  nerve. 
See  Atrophy  of  optic  nerve,   con- 
secutive. 
Potassium  iodid,  59,  517 
in  acquired  ptosis,  100 
in  choroiditis,  345,  346 
in  chronic  dacryoadenitis,  120 
in  cyclitis,  269 
in  detachment  of  retina,  363 
in  diseases  of  the  eye,  59 
in  episcleritis,  245 
in  facial  paralysis,  107 
in  glaucoma  simplex,  293 
in     hemorrhage     into     vitreous 

chamber,  337 
in     hypertrophy     of      lacrimal 

gland,  124 
in  interstitial  keratitis,  229,  230 
in  iritis,  262,  263,  264,  265 
in  neuropathic  keratitis,  222 
in  optic  neuritis,  373 
in  paralysis   of    ciliary  muscle, 

432 
of  external  rectus,  443 
of  third  nerve,  446 
in  periostitis  of  orbit,  112 
in  retinitis  albuminurica,  351 
in  retrobulbar  optic  neuritis,  375 
in  scleritis,  244 
in  secondary  glaucoma,  294 
in  syphilitic  orbital  growths,  117 
retinitis,  353 
Prelacrimal  abscess,  137 
Presbyopia,  297,  427 
advent  of,  428 
a  progressive  condition,  429 
asthenopia  from  neglect  of,  428 
decline   of,   in  incipient  stage   of 

cataract,  302,  430 
explanation  of,  427,  428 
how  influenced  by  ametropia,  399, 

428,  429 
late  development  of,  428 
symptoms  of,  32,  428 
treatment  of,  429,  430 
bifocal  lenses  in,  430 


544 


INDEX. 


Presbyopia,  treatment  of,  fallacy  of 
the  popular  belief  that  little 
skill  is  required  in  selection 
of  glasses  in,  429 
glasses  the  only  remedy  in,  429 
Primary  atrophy  of  optic  nerve,  378 
Prismatic  glasses,  471 
Prisms  from  trial  case  in  measure- 
ment of  heterophoria,  469 
in  correction  of  squint,  462 
in  esophoria,  475 
in  exophoria,  422 
in  hyperphoria,  478 
in   subnormal    accommodative 
power,  437 
Protargol,  51,  157,  169 
in  dacryocystitis,  137 
in  purulent  conjunctivitis,  164,  168 
in     trachomatous     conjunctivitis, 
180,  181 
Pseudo-pt  rygium,  197 
Pterygium,  195 
description  of,  195 
etiolog}^  of,  197 

genesis  of,  author's  theon,'  of,  198 
impairment  of  vision  from,  196 
operation  for  removal  of,  199 
treatment  of,  198 
Ptomaine  poisoning,  431 
Ptosis,  98 
acquired,  98 
etiolog}-  of,  98 
symptoms  of,  98 
treatment  of,  100 
Bowman's  operation  for,  102 
congenital,  98 

characteristic  facial  expression, 

in,  99 
etiolog}^  of,  98 
treatment  of,  99,  loi,  102,  103, 

104,  105 
vicarious    action     of    occipito- 
frontalis  in,  98 
de  Grandmont's  operation  for,  102 
Gruening's  operation  for,  102,  103 
Panas's  operation  for,  104,  105 
varieties  of,  98 
Pulsation  of  retinal  vessels,  279 
Puncta     lacrimalia.     See    Lacrimal 

pun  eta. 
Pupil,  24 

Arg}ll  Robertson,  27 
consensual  reflex  action  of,  25 
direct  reflex  action  of,  24 
enlargement  of,  in  glaucoma,  277, 

291 
occlusion  of,  in  iritis,  2J0,  250,  2^4, 
.258 
Pupillary  reactions,  24 


Pupils,  associated  action  of,  25 
normal     variations    in    size    and 

activity  of,  25 
size  of,   influenced    by   refractive 

state  of  eyes,  25 
size  and  reactions   of,  conditions 

which  influence,  25 
unequal  size  of,  in  anisometropia. 

Purulent  choroiditis,  340.     See  also 
Panophthalmitis,  purulent. 
conjunctivitis.      See    Conjunctivi- 
tis, purulent. 
cyclitis.     See  Cyclitis,  purulent. 
iritis.     See  Iritis,  purulent. 
panophthalmitis.      See     Panoph- 
thalmitis, purulent. 
Pyramidal  cataract,  321 
Pyrophospate  of  sodium.     See  So- 
dium pyrophospate. 


Questions    helpful   in   reaching   a 

diagnosis,  31 
Quinin  blindness,  377 

patholog}-  of,  377,  378 

symptoms  of,  377,  378 

treatment  of,  378 
in  neuropathic  keratitis,  221 
in  purulent  cyclitis,  269 

iritis,  262,  265 
in  suppurative  keratitis,  206,  212 
value  of,  in  abscess  and  ulcer  of 

cornea,  60 


Randolph,  R.  L.,  186 
Rays  of  light,  parallel,  393 

course  of,  in  emmetropic  eye, 

393 
in  hvpermetropic  eve,  395, 

398 
in  myopic  eye,  403,  404 
Reading    distance,     importance    of 

testing  muscle-balance  for,  469 
Reconstruction  of  lid  margin  (Hotz) 

in  entropion,  87 
Reflex  dental  irritation  in  keratitis, 
222 
paralysis    of    ciliarj'    muscle 

from,  223 
spasm   of   orbicularis  palpe- 
brarum from,  223 
Refraction,  anomalies  of,  388 
Refractive  and  muscular  anomalies, 
svmptoms  which  suggest  existence 
of,  32 


INDEX. 


545 


Remedies,    constitutional,    useful  in 

diseases  of  the  eye,  39 

formulae  for,  516-520 

observations  upon,  57-62 

local,  useful  in  diseases  of  the  eye, 

39 
formulae  for,  505-515 
observation  upon,  39-57 
Retina,  detachment  of,  360,  491 

cataract  a  late  complication  in, 

363 

diagnosis  of,  363 

etiolog)'  of,  361 

far-fetched   theories   of   genesis 
of,  361 

in  high  myopia,  342,  361 

in  intraocular  growths,  362 

subconjunctival  injection  of  salt 
solution  in,  363 

symptoms  of,  362,  363 

treatment  of,  363,  364 

unfavorable  prognosis  in,  363 
diseases  of,  348 
glioma  of,  364 

a  disease  of  childhood,  365 

clinical  course  of,  365,  366,  367 

diagnosis  of,  364,  365 

malignancy  of,  366 

symptoms  of,  365,  366 

treatment  of,  366,  367 

unfavorable  prognosis  in,  367 
pigmentary  degeneration  of,   354 
Retinal  artery,  emboHsm  of,  357 

pulsation  in,  279 

thrombosis  of,  359 
Retinitis,  348 
albuminuric,  349 

etiology  of,  349 

impairment   of   vision   in,    349, 

350 
in  pregnancy,  349>  35 1 
in  scarlatina,  349,  351 
ophthalmoscopic  picture  of,  350 
pathology  of,  350 
prognosis  in,  351 
treatment  of,  351 
uremic  amblyopia  in,  351 
diabetic,  351 

cataract  in  association  with,  351 
fundus  changes  in,  351 
impairment    of    vision    in,    352 
iritis  and  glaucoma  in  associa- 
tion with,  351 
prognosis  in,  352 
treatment  of,  352 
from  exposure  of  the  eyes  to  in- 
tense light,  353 
conjunctivitis     in     asso- 
ciation with,  354 

35 


Retinitis   from  exposure  of  the  eyes 
to  intense  light,  fundus 
changes  in,  353 
how  produced,  353 
prognosis  in,  354 
symptoms  of,  353 
treatment  of,  354 
hemorrhagic.     See  Thrombosis  of 

central  retinal  vein. 
leucocythemic,  352 

ophthalmoscopic  picture  of,  352 
pathology  of,  352 
treatment  of,  352 
of  pernicious  anemia,  352 
fundus  changes  in,  352 
prognosis  in,  352 
treatment  of,  352,  353 
parenchymatous,  348,  349 
pigmentosa,  354 

clinical    historv    of,    354,    355, 

356 
congenital  anomalies  frequently 

associated  with,  354 
development  of  posterior  polar 

cataract  in,  356 
etiology  of,  354 
in  association  with  deaf-mutism, 

354 
night-blindness  a  characteristic 

symptom  of,  355 
nystagmus      not      infrequently 

present  in,  355 
ophthalmoscopic      picture     of, 

355 
pathology  of,  355 
progressive  contraction  of  visual 

field  in,  355 
slow  progress  of,  354,  355 
symptoms  of,  355 
treatment  of,  356 
unfavorable  prognosis  in,  355 
primary,  349 
secondary,  349 
symptoms  of,  348 
syphilitic,  353 

fundus  changes  in,  353 
prognosis  in,  353 
treatment  of,  353 
varieties  of,  348 
Retino-choroiditis.     See     Choroido- 

retinitis. 
Retinoscopy,  422 
Retrobulbar  neuritis,  374 
Rheumatic  diathesis,  244,  389 
Rheumatism,    119,    242,    248,     268, 

291.  374 
"Ring  ulcer"  of  cornea,  211 
"Ripeness"  of  cataract,  determina- 
tion of,  307 


546 


INDEX. 


Risley,  S.  D.,  on  the  lessened  preva- 
lence of  high  myopia  in  the  United 
States,  406 

Roller-forceps,  Knapp's,  181,  182 
in  vernal  conjunctivitis,  1S6 

Rontgen-ray  apparatus,  Sweet's,  500 

Rontgen-rays  in  detection  of  foreign 
bodies  in  eyeball,  499,  500,  501, 
503 


Salicylate    of    sodium.     See    So- 
dium salicylate. 
Salicylates,  the,  in  inflammatory  con- 
ditions of  eye,  59 
Salicylic  acid,  ointment  of,  514 
in  blepharitis,  66 
eczema  of  lids,  71 
vernal  catarrh,  185 
Salt    solution,    subconjunctival    in- 
jections of,  in  detachment  of  retina, 

363,  364 
Sarcoma  of  choroid,  347,  34S 

of  ciliary  body,  269 

of  lacrimal  gland,  125 

of  lid  and  orbit,  80 

of  orbit,  115 
Sattler's  diplococcus,  174 
Schlemm's  canal,  282 
Sclera  and  ciliary  body,  wounds  of, 

494,  495 

diseases  of,  242 
Scleritis,  242 

acute,  242 

chronic,  243 

diagnosis  of,  243 

etiology  of,  242 

symptoms  of,  243 

treatment  of,  243 

usually    of    rheumatic    or    gouty 
origin,  242 

varieties  of,  242 
Sclero-conjunctivitis,  242 
Sclero-keratitis,  242 
Sclerosis  of  lens  fibers,  295 
Sclerotitis.     See  Scleritis. 
Scopolamin,  48 
Scotoma,  central,  353,  376 

color,  376 

paracentral,  374 
Scrofulous  conjunctivitis,  186,  188. 
Sec  also    Cottjutictivitis,  phlyc- 
tenular. 

ophthalmia,    188.     See  also  Con- 
junctivitis, phlyctenular. 
"Second sight"  a  premonitory^  symp- 
tom of  cataract,  302,  306 
Secondary   cataract.     See   Cataract, 

capsular. 


Seed-shells  lodged  on  cornea,  488 
easily  overlooked,   488 
peculiar  behavior  of,  488 
Senile,  236 

cataract,  298,  299,  300,  301,  302 
changes  in   crystalline   lens,    295, 

296,  297 
decay,  302 
Senilis,  arcus,  235 
Senility,  208 
Serous   cyclitis.     See   Iritis,    serous. 

iritis.     See  Iritis,  serous. 
Serpent  ulcer  of  cornea,  211 
Shadow  test,  222 

Shortening  lid,  von  Ammon's  oper- 
ation for,  93 
Short-sightedness.     See  Myopia. 
Sichel's  cataract  knife,  145 
Silver  foil  as  a  dressing  in  lid  oper- 
ations, 96 
as  a  surgical  dressing,  suggested 
by  Halsted,  96 
nitrate  in  blepharitis   marginalis, 
66,  515 
in  purulent  conjunctivitis,    164, 

168 
in    severer    types    of    conjunc- 
tivitis, 51 
in  trachomatous  conjunctivitis, 
180,  181 
Simple  atrophy  of  optic  nerve,  378 
glaucoma.     See  Glaucoma,  simple. 
Simulated  blindness,  ^^ 
Sixth     nerve,      paralysis     of.      See 
Paralysis  of  external  rectus  muscle. 
Skiagraphy  in    detection  of  foreign 
bodies  in  eyeball,  499,  500,  501, 

503 
Skiascopy,  422 
Skin-grafting,  88,  94,  95,  96,  97 

silver-foil  as  dressing  in,  96,  98 
Smith's,  Nathan  R.,  knife  for  divid- 
ing strictures  of  the  nasal  duct,  142 
Snellen's    operation    for    spasmodic 
ectropion,  92 
test-types,  27 
Sodium  chlorid,  formula  for  collyr- 
ium  of,  505 
subconjunctival     injection     of, 

238,  3^7,  3(>3'  364 

with  bichlorid  of   mercury,  51, 
506 
pyrophosphate  in  cellulitis  of  orbit, 
no 

in  dacryoadenitis,  120 

in  dacryocvstitis,  136 

value  of,  in  suppurative  proc- 
esses of  the  lids,  lacrimal  sac, 
and  orbit,  62 


INDEX. 


547 


Sodium  salicylate,  59,  518 
in  choroiditis,  346 
in  cyclitis,  269 
in  episcleritis,  245 
in  glaucoma,  289 
in  iritis,  262,  263 
in  optic  neuritis,  373 
in   periostitis   of    orbital  walls, 

III 
in  retrobulbar  optic  neuritis,  375 
in  scleritis,  244 
in  secondary  glaucoma,  294 
in  severe  contusions  of  eye,  493 
in     sympathetic     ophthalmitis, 

265 
in  traumatic  choroiditis,  346 
Solar  retinitis,  353 
Somnolency  induced  by  eye-strain, 

390,  418 
Spasm  of  accommodation,  432 
of  ciliar}'  muscle,  432 
etiology  of,  432 
from  eserin,  432 
symptoms  of,  432 
transient    myopia    produced 

by,  432 
treatment  of,  433 
true    refractive    condition    of 

eyes  masked  by,  432 
uncorrected     astigmatism     a 
common  cause  of,  432 
Spectacles,  429 

bifocal,  430 
Sphincter  pupillas,  paralysis  of,   26, 

431.  445. 
undue  contraction  of,  26,  379 
"Spongy"  iritis,  259 
Spring  catarrh.     See  Conjunctivitis, 

vernal. 
Squint,  concomitant,  448 

alternating,  448,  451,  554 
amblyopia    of    misdirected    eye 
in,  449 
how  induced,    449,    450, 

451 
not  an  example  of  "am- 
blyopia      exanopsia," 

449 
origin  of,  not  merely  of 
theoretical  interest,  45 1 
regional  character  of,  450 
significance  of,  450 
characteristics  of,  448 
consequences  of,  449 
constant,  448 
convergent,  453 

etiology'  of,  396,  397,  453,  454 
Bonders'   dicta    regarding, 
397.  453 


Squint,      concomitant,      convergent, 

hypermetropia  most  potent 

factor  in  causation  of,  397 

in  myopia,  454 

oftenest     develops    in     early 

childhood,  453 
treatment  of,  402,403,455,456 
by  glasses  alone,  402,  455, 

456 
by  operation,  455,  457,  458, 
459,  460,  461,  462 
definition  of,  448 
detection  of,  452 

cover  test  in,  452 
divergent,  463 

development    of,  in  myopia, 

464 
etiology  of,  407,  40S,  463 
may  develop  at  any  time  of 

life,  463,  464 
myopia  most  potent  factor  in 

causation  of,  463,  464 
seldom  alternating,  464 
treatment  of,  464 

by  glasses  alone,  464,  465 
by  operation,  465,  466 
etiology  of,  438,  439,  448 
periodic,  448,  454 
priroar}',  452 
secondary,  451,  452 
varieties  of,  448 
detection  of,  452 
paralytic,  440 
diagnosis  of,  441 
diplopia  a  characteristic  symp- 
tom of,  441 
etiology  of,  441,  442 
external  rectus  oftenest  involved 

in,  442 
pathology  of,  441,  442 
symptoms  of,  441 
priman,',  452 
secondary,  451,  452 
vertical,  466 
etiology  of,  466 
glasses    of    little    assistance    in 

correction  of,  466 
treatment  of,  466 
Squints,  439 

characteristic  features  of,  439 
due  solely  to  muscular  faults,  rare, 

439 
etiolog}'  of,  439 

of  paralytic  origin  occur  at  any 
time  of  life,  439 
Staphylococcus  aureus  in   keratitis, 
204,  210 
in  phlyctenular     conjunctivitis, 


548 


INDEX. 


Staphyloma,  anterior.     See  Staphyl- 
oma oj  cornea. 
of  cornea,  i6i,  239 
anatomy  of,  239 
etiolog}-  of,  239 
impairment  of  vision  in,  239 
iridectomy  for,  241 
Knapp's  operation  for,  241 
partial,  239 
total.  239 
treatment  of,  240 
posterior,  in  myopia,  404,  406,  408 
Sterilization  of  colly ria,  501 

of  instruments   by    brief   boiling, 
144 
Stilling,  142 
Stillson,  364 

Strabismus.     See  Squint. 
Streptococcus  in  suppurative    kera- 
titis, 204,  211 
Stricture  of  canaliculus,  130 
of  nasal  duct,  137 

division     of,     practised     by 
Nathan  R.  Smith,  in  1846, 
142 
etiology-  of,  137,  138,  139 
location  of,  139 
Nathan  R.  Smith's  knife  for 

dividing,  142 
often  consequent  upon  nasal 

disease,  138 
often  multiple,  139,  140 
transient,  in  new-born,  150 
treatment  of,  140-150 

employment  of  large  probes 
_  in,  143,  146 
varieties  of,  140 
Strumous  diathesis,  191 
Strychnin,  519 

in  acquired  ptosis,  100 
in  diseases  of  the  eye,  60 
in  facial  paralysis,  107 
in  neuropathic  keratitis,  222 
in  paralysis  of  ciliarj'  muscle,  432 
of  si.xth  nerve,  443 
of  third  ner\-e,  446 
in  primarv  atrophv  of  optic  nerve, 

in  quinin  blindness,  378 

in  retinitis  pigmentosa,  356 

in  retrobulbar  optic  neuritis,  375, 

377 
in    secondary'    atrophy    of    optic 

nerve,  382 
preferably    administered    by    the 
mouth,  60 
Stye.     See  Hordeolum. 
Subconjunctival  hemorrhage,  193 
diagnosis  of,  194 


Subconjunctival   hemoirha;5e,   etiol- 
ogy of,  194 
treatment  of,  194 
injection  of  salt  solution,  238,  337, 

3(^2,,  364 
I    Subnormal    accommodative    power, 

433 

a  not  infrequent  cause  of  as- 
thenopia, 433 
asthenopia,  how  produced  in, 

435 
described  by  author  in  1891, 

433 
early    development    of    pres- 
byopia a  manifestation  of, 

434 
how  detected,   434,  435,  436 
may    exist   independently    of 
other  faults,  or  may  com- 
plicate other  errors,  refrac- 
tive or  muscular,  433 
of  transient   character,    after 

use  of  cycloplegic,  435 
rule  for  correction  of,  436 

for  detection  of,  435 
symptoms  of,  433,  434,  435 
treatment  of,  436,  437 

when    complicated    by    re- 
fractive or  other  muscu- 
lar faults,  436 
satisfactor}-  results  of,  437 
underlying  causes  of,  433,  435 
"Sugar  of  lead,"  237 
Sulphate    of    copper.     See    Copper 

sulphate. 
Sulphonal,  60 
Superficial      lodgment     of     foreign 

bodies  in  eye,  486 
Superior  oblique   muscle,    paralysis 
of.     See     Paralysis     of    superior 
oblique  muscle. 
Suspensor}-  Hgament  of  lens,  295,  328 
Sweet's  electro-magnet,  499,  503 
localizing  chart,  502 
Rontgen-ray  apparatus,  500 
Symblepharon,  480,  481,  482,  483 
Sympathectomy,  293 
Sympathetic  iritis.     See  Iritis,  sym- 
pathetic. 
irritation,  257 

prompt  disappearance  of,  upon 

removal  of  exciting  eye,  257 
symptoms  of,  257 
ophthalmitis,  250,  256,  281,  493, 
497,    504.      See    also    Iritis, 
sympathetic. 
etiology-  of,  256,  258,  259 
Sympathizing  eye,  257,  258,  259 
Synchysis,  334 


INDEX. 


549 


Synechia,  anterior,  37,  161,  206,236, 

254,  293,  294,  494,  504 
posterior,  21,  26,  37,  247,  249,  250, 

252,    254,    255,    258,    259,    260, 

267,  293,  294 
Syphilis  a  common  cause  of  retinitis, 

349 
acquired  ptosis  oftenest  due  to,  98 
a  factor  in  causation  of  lacrimal 

stricture,  139,  149 
cataract  in  inherited,  302 
characteristic  physiognomy  of  in- 
herited, 227,  228 
commonest  cause  of  iritis,  248,  255 
disease   of   deeper   tunics   of   eye 

often  dependent  upon,  339 
facial  paralysis  from,  106 
importance  of  role  played  by,  in 
etiology  of  diseases  of  the  eye, 

57 
in  acute  retrobulbar  neuritis,  374 
in  choked  disc,  372 
in  dacryoadenitis,  119 
in  descending  optic  neuritis,  372 
in  hemianopsia,  385,  386 
in  paralysis  of  ciliary  muscle,  430 

of  ocular  muscles,  441 
in  primary  atrophy  of  optic  nerve, 

379 

in  retinitis,  353 

interstitial  keratitis  due  to  in- 
herited, 223 

iritis  in  inherited,  226,  255 

notched  and  pegged  teeth  in  inher- 
ited, 227 

observations  upon   treatment   of, 

paralysis  of  third  nerve  oftenest 

due  to,  444 
periostitis  of  orbit  oftenest  due  to, 

III 
plastic  choroiditis  oftenest  due  to, 
340,  342 

cyclitis  from,  268 
tarsitis  from,  79 
tumors  of  orbit  due  to,  114,  115, 

117 

zonular  cataract  in  inherited,  324 
Syphilitic  choroiditis.  See  Choroid- 
itis, syphilitic. 

iritis.     See  Iritis,  syphilitic. 

keratitis.  See  Keratitis,  intersti- 
tial. 

retinitis,  353 


Tabes  dorsalis,  378 
Tarsal  cartilages,  85 
cvst.     See  Chalazion. 


Tarsitis,  79 

treatment  of,  80 

usually  consequent  upon  acquired 
syphihs,  79 
Tattooing  of  cornea,  238 
Teeth,  "dead,"  222 
Hutchinson,  227 
Tenon's     capsule,    division    of,    in 
"free  "  tenotomies,  459 
non-division  of,  in  "guarded" 
tenotomies,  477 
Tenotomies,  graduated,  little  better 

than  a  pretence,  477 
Tenotomy,  455,  457,  458,  459,  460, 
461,  462,  465 
adrenalin  helpful  in  operation  of, 

461 
Arlt's  method  of  performing,  457, 

465 
awkward  methods  of  performing, 

formerly  in  vogue,  462 
best  method  of  performing,  457 
description  of  operation  of,  457 
early  resort  to,  indicated  in  con- 
vergent squint,  462 
for  correction  of  convergent  squint, 

-^57.      .. 
how    sinking    of    caruncle 
may  be  prevented  in,  459 
why  preferable  to  advance- 
ment, 457 
of  divergent  squint,  465 
of  esophoria,  475,  476 
of  exophoria,  472 
of  hyperphoria,  478,  479 
had  best  be  "guarded,"  478 
indications  for,  478 
little   assistance   afforded   by 

glasses  in,  478 
uncertainties    which    attend, 
478,  479 
of    latent  muscular   anomalies, 

471,  476,  477 
of  vertical  squint,  466 
"guarded,"  413,  477,  478 
how  effect  of,   may  be  modified, 

459>  477 
in  children,  461 
infection    almost    unheard    of    in 

operation  of,  461 
instruments  required  in  perform- 
ing, 458 
operation  of,  practically  free  from 
risk,  461 
Tension,  intraocular,  23,  282 

increase   of,    collyria   indicated 
in,  508,  509 
in  glaucoma,   274,   276,   278, 
280,  282,  291 


550 


INDEX. 


Tension,    intraocular,    increase    of, 
in  glioma  of  retina,  365 
in  intraocular  growths,  363 
in  serous  iritis,  252,  261 
method     of     determining     and 

noting,  23,  24 
subnormal,  282 

in  detachment  of  retina,  363 
Theobald's    lacrimal    probes,     141. 

See  also  Author's. 
Therapeutic  agents  called  for  in  the 
treatment  of  diseases  of  the  eye, 

39 
Thiersch-grafts     in     correction      of 
ectropion,  94,  97 
of  entropion,  88 
silver-foil  as  covering  for,  96 
Third     nerve,     paralysis     of.     See 

Paralysis  of  oculomotoriiis. 
Thrombosis    of    central    artery    of 
retina,  359,  381 
etiology  of,  359 
post-hemorrhagic  blindness 

probably  due  to,  359 
symptoms  of,  359 
treatment  of,  359 
retinal  vein,  359,  381 
consequences  of,  359 
etiology  of,  359 
ophthalmoscopic   picture   of, 

360 
treatment  of,  360 
Tinnitus    aurium   from    eye-strain, 

390 
Tobacco   a   factor  in   causation   of 

retrobulbar  neuritis,  376 
Toxic   amblyopia.     See   Optic   neu- 
ritis, retrobulbar,  chronic. 

conjunctivitis,  192 
Trachoma.     See  Conjunctivitis,  tra- 
chomatous. 

usual  cause  of  organic  entropion, 
81 
Transient  hemianopsia,  386 
Treatment  of  diseases  of  the   eye, 

general  observation  upon,  38-62 
Trional,     administration    of,     after 

operations  upon  the  eye,  60 
"Trituration"  of  lens,  313 
Trochlear  nerve,  paralysis  of.     See 

Paralysis     of     superior     oblique 

muscle. 
"Trophic    nerve"    keratitis.        See 

Keratitis,  neuropathic. 
Tuberculosis  of  lacrimal  gland,  119 

of  nose,  139 
Tuberculous  periostitis  of  orbit,  1 1 1 
Tumors  of  choroid,  348 

of  ciliary  body,  269 


Tumors  of  orbit,  113 

diagnosis  of,  115 

etiology  of,  113 

treatment  of,  116 

varieties  of,  114 
of  retina,  364 
Turkish  bath  in  iritis,  262,  266 
Typhoid  fever,  208 


Ulcer    of   cornea,    207.     See   also 

Cornea,  ulcer  of. 
Uremic  amblyopia,  351 
Urine,    importance    of    testing,    in 
optic  neuritis,  373 
in  retinitis,  350 
Uveitis,  252 


Vascular     injection     of      eyeball, 
significance  of  different  types  of, 

35 
"Vaseline  cerate,"  formula  for,  46, 

513 
Velpeau's  operation  for  removal  of 

lacrimal  gland,  124 
Venae  vorticosa?,  282 
Veratriae  oleate,  formula  for,  515 

indications  for,  5 1 5 
Vernal  conjunctivitis,  183 
Vertical  diplopia  test  of  von  Graefe, 
469 
squint,  466 
Vertigo,  in  ametropia,  390 
in  astigmatism,  418 
in  heterophoria,  467 
in  paralytic  squint,  439,  443 
Visual  acuity,  determination  of,  27 
for  near  objects,  28 
when  sight  is  greatlv  impaired, 
28 
Vitreous  humor,  diseases  of,  333 
fluidity  of,  334 

consequences  of,  334 

etiology  of,  334 

oftenest  met  with  in  myopia, 

334 
hemorrhage  into,  336 
absorption  of,  337 
effect  upon  vision  of,  337 
etiology  of,  336 
ophthalmoscopic  appearances 

of,  337 
origin  of,  336 
serious  consequences  of,  when 

recurrent,  337 
treatment  of,  337 
opacities  of,  334 
diagnosis  of,  335 


INDEX. 


551 


Vitreou?  humor,  opacities  of,  disap- 
pearance of,  335 
disturbance    of    vision   from, 

335 

etiology  of,  335,  336 

of  little  moment  when  micro- 
scopic, 335 

treatment  of,  336 

varieties  of,  335 


Warts  upon  lid  margin,  78 

treatment  of,  78 
Weber's  canaliculus  knife,  129 
Weeks'  bacillus,  156 
Weeks  on  bacteriology  of  phlycten- 
ular conjunctivitis,  189 
WilHams,  E.,and  H.  D.  Noyes,  first 

to  use  large  lacrimal  probes,  140 
Wolfe-grafts  in  operations  for  ectro- 
pion, 94 
Wounds.     See  also  Injuries. 

of  eye  complicated  by  lodgment 
of  foreign  bodies 
within     the     ball, 

497 

cataract  caused    bv, 

498 
consequences  of ,  497, 

498,  499,  504 
danger  of   infection 

in,  497 
interesting  cases  of, 

498>  503 

sympathetic  oph- 
thalmitis from, 
497,  498,  504 

treatment  of,  499 
antiseptic  precau- 
tions in,  501 
electro-magnet  in, 

499.  500.  503 
enucleation  of  eye 

not  infrequently 
demanded     in, 

504 
pain-reaction  test 

in,  500 
skiagraphy  in,  499, 

500,  501 

when  foreign  body 
is  non-magnetic, 
502 
penetrating,  494 


Wounds  of  eye,  penetrating,  always 
of     serious    concern,    494, 

495 

antiseptic  precautions  de- 
manded in,  495,  496 

compHcated  by  involvement 
of  lens,  494 

consequences  of,  494 

danger  of  infection  occurring 
in,  494,  495 

enucleation  of  injured  eye  in, 

495.  497 
"  first  aid"  in,  495,  496 
hernia  of  iris  and  ciliary  body 

from,  494 
involving    the    choroid    and 
retina,  495 

the  cornea,  iris,   and  lens, 

494,  497 
the  sclera  and  ciliary  body, 

494>  497 
sympathetic  ophthalmitis 

from,  497 
traumatic  cataract  a  not  un- 
common result  of,  495 
treatment  of,  495,  496,  497 
of  eyelids,  480 
Wyeth's  elixir  of  phosphates  of  iron, 
quinin,  and  strychnin,  60 

Xerophthalmia,  176 
X-rays.     See  Ront gen-rays. 

Yellow  o.xid  of  mercury.     See  Mer- 
cury, yellov:  oxid. 

Zinc  oxid  and  boracic  acid,  ointment 
of,  71 
formula  for,  513 
sulphate,  50 

contraindicated  in  phlyctenular 

conjunctivitis,  189 
formula  for  collyrium  of,  506 
in  catarrhal  conjunctivitis,   50, 

157 
in  follicular  conjunctivitis,   173 
in  hordeolum,  69,  515 
in    membranous  conjunctivitis, 

169 
in  vernal  conjunctivitis,  185 
Zonular  cataract,  324 
Zonule  of  Zinn,  295,  328 


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A.  C.  Abbott,  M.D. 
Isaac  A.  Abt,  M.D. 
.Sir  Clifford  Allbutt,  M.D. 
James  M.  Anders,  M.D. 
John  F.  Anderson,  M.D. 
Lewellys  F.  Barker,  M.D. 
Joseph  C.  Bloodgood,  M.D. 
George  Blumer,  M.D. 
Sir  Lauder  Brunton,  M.D. 
Charles  W.  Burr,  M.D. 
Richard  C.  Cabot,  M.D. 
James  Carroll,  M.D. 
John  G.  Clark,  M.D. 
Rufus  I.  Cole,  M.D. 
Warren  Coleman,  M.D. 
Matthew  H.  Cryer,  M.D. 
Clinton  T.  Dent,  M.C. 
Francis  X.  Dercum,  M.D. 
George  E.  deSchweinitz,  M.D. 
George  Dock,  M.D. 
Isadore  Dyer,  ^LD. 
David  L.  Edsall,  M.D. 
William  A.  Edwards,  M.D. 
Arthur  W.  Elting,  M.D. 
John  M.  T.  Finney,  M.D. 
Charles  H.  Frazier,  M.D. 
M.  Howard  Fussell,  M.D. 
Thomns  R.  Futcher,  ^LD. 


John  H.   Gibbon,  M.D. 
Joel  E.  Goldthwait,  M.D. 
Edward  H.  Goodman,  M.D. 
Samuel  McC.  Hamill,  M.D. 
Hobait  A.  Hare,  M.D. 
Charles  Harrington,  M.D, 
Ludvig  Hektoen,  ^LD. 
Albion  Waher  Hewlett,  M.D. 
Guy  Hinsdale,  ^LD. 
John  Homans,  M.D. 
Guy  L.  Hunner,  M.D. 
Chevalier  Jackson,  M.D. 
Henry  Jackson,  M.D. 
Theodore  C.  Janeway,  M.D. 
J.  H.  Jobson,  M.D. 
Maynard  Ladd,  M.D. 
Egbert  Lefevre,  M.D. 
James   Hendrie  Lloyd.  M.D. 
G.  Hudson-Makuen,  ^LD. 
Charles  F.  Martin,  ^L  C. 
Edward  Martin,  M.D. 
Charles  H.  Mayo,  iNLD. 
William  J.  Mayo,  M.D. 
Alexius  McGlannan,  M.D. 
R.  Tait  McKenzie,  M.D. 
Herbert  C.  Moffitt.  M.D. 
Jesse  M.  Mosher.  M.D. 


B.  G.  A.  Moynihan,  M.  S. 
George  P.  Muller,  M.D. 
John  H.  Musser,  M.D. 
Edward  O.  Otis,  M.D. 
Henry  K.  Pancoast,  M.D. 
Roswell  Park, -M.D. 
Richard  M.  Pearce,  M.D. 
George  M.  Piersol,  M.D. 
Charles  W.  Richardson,  M.D. 
David  Riesman,  M.D. 
Samuel  Robinson,  M.D. 
Milton  T-  Rosenau,  M.D. 
Joseph  Sailer,  M.D. 
J.  F.  Schamberg,  M.D. 
Henry  Sewall,  M.D. 
Bertram  W.  Sippy,  M.D. 
William  G.  Spiller,  M.D. 
J.  Dutton  Steele,  M.D. 
Alfred  Stengel,  M.D. 
Charles  G.  Stockton.  M.D. 
James  E.  Talley,  ^LD. 
E.  W.  Taylor,  M.D. 
James  Tyson,  M.D. 
George  H.  Weaver,  M.D. 
J.  William  White,  M.D. 
Alfred  C.Wood,  M.D. 
Horatio  C.  Wood,  Jr.,  .\LD. 


DIAGNOSIS  AND    TREATMENT. 


Cabot's 
Differential  Diagnosis 

Differential    Diagnosis.     Presented    through   an   Analysis   of   385 

Cases.     By  Richard  C.  Cabot,  M.  D.,  Assistant  Professor  of  Clinical 

Medicine,  Harvard   Medical    School,   Boston.     Octavo    of  764  pa-^es, 

illustrated.  Cloth,  ;$5.50  net. 

THE  NEW   (2d)  EDITION 

FOUR  PRINTINGS  AND  TWO  EDITIONS  IN  ONE  YEAR 

Dr.  Cabot's  work  takes  up  diagnosis  from  the  point  of  view  of  Xht. presenting 
symptom — the  symptom  in  any  disease  which  holds  the  foreground  in  the  chnical 
picture  :  the  principal  complaint.  It  groups  diseases  under  these  symptoms,  and 
points  the  way  to  proper  reasoning  in  coming  to  a  correct  diagnosis.  It  works 
backward  from  each  leading  symptom  to  the  actual  organic  cause  of  the  symptom. 
This  the  author  does  by  means  of  case-teachmg. 

Chas.   Lyman   Greene,  M.D.,   University  of  Minnesota. 

"  It  is  one  of  the  most  valuable  books  that  has  been  published  in  recemt  years,  or  indeed  at 
any  time." 


Morrow's  Diagnostic  and 
Therapeutic  Technic 

Diagnostic  and  Therapeutic  Technic.  By  Albert  S.  Morrow, 
M.  D.,  Adjunct  Professor  of  Surgery,  New  York  Polyclinic.  Octavo 
of  775  pages,  with  815  original  line  drawings.     Cloth,  ;$5.00  net. 

JUST  THE  WORK  FOR  PRACTITIONERS 

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those  procedures  required  of  you  every  day,  and  it  tells  you  and  shows  you  by 
clear,  new  line-drawings,  in  a  way  never  before  approached.  It  is  not  a  book  on 
drug  therapy  ;  it  deals  alone  with  physical  or  mechanical  diagnostic  and  thera- 
peutic measures.  The  information  it  gives  is  such  as  you  need  to  know  every 
day — transfusion  and  infusion,  hypodermic  medication,  Bier's  hyperemia,  explora- 
tory punctures,  aspirations,  anesthesia,  etc.  Then  follow  descriptions  of  those 
measures  employed  in  the  diagnosis  and  treatment  of  diseases  of  special  regions  or 
organs:  proctoclysis,  cystoscopy,  etc. 
Journal  American  Medical  Association 

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Bonney  on  Tuberculosis 


Tuberculosis.      By    Sherman    G.    Bonney,    M.    D.,    Professor   of 
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Anders  (b  Boston's  Medical  Diag'nosis 


A  Text=Book  of  Medical  Diagnosis. — By  James  M.  Anders,  M.D., 
Ph.D.,  LL.D.,  Professor  of  the  Theory  and  Practice  of  Medicine  and  of 
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diagnostic  methods  are  presented  in  a  forceful,  definite  way  by  men  who  have 
had  wide  experience  at  the  bedside  and   in  the  clinical  lalioratorv. 

The  Medical  Record 

"  The  association  in  its  authorship  of  a  celebrated  clinician  and  a  well-known  laboratory 
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PRACTICE   OF  MEDICINE 


Kemp   on 
Stomach  and  Intestines 

Diseases  of  the  Stomach  and  Intestines.  By  Robert  Coleman 
Kemp,  M.  D.,  Professor  of  Gastro-intestinal  Diseases  at  the  New 
York  School  of  CHnical  Medicine.  Octavo  of  icxDO  pages,  with  378 
illustrations. 

JUST  READY— NEW  (2dj  EDITION 

Of  the  many  works  on  gastro-intestinal  diseases,  this  is  perhaps  the  only  one 
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It  is  the  practitioner  who  first  meets  with  these  cases,  snd  it  is  he  upon  whom  the 
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properly  equipped,  could  frequently  treat  the  case  himselt  instead  of  transferring 
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Deaderick     on     Malaria 

Practical  Study  of  Malaria.  By  William  H.  Deaderick,  M.  D., 
Member  American  Society  of  Tropical  Medicine ;  Fellow  London 
Society  of  Tropical  Medicine  and  Hygiene.  Octavo  of  402  pages, 
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UP    (O  DATE 


Niles  on  Pellagra 

Pellagra.  By  George  M.  Niles,  M.  D.,  Professor  of  Gastro- 
enterology and  Therapeutics,  Atlanta  School  of  Medicine.  Octavo  of 
253  pages,  illustrated.     Cloth,  ^3.00  net. 

This  is  a  book  you  must  have  to  get  in  touch  with  the  latest  advances  con- 
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and  the  fifst  in  any  language  adequately  covering  diagnosis  and  treatment. 
Pathology,  heretofore  an  echo  of  European  views  only,  is  here  presented  from  an 
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Tousey*s 

Medical  Electricity  and  X-Rays 

Medical  Electricity  and  the  X=Rays.  By  Sinclair  Tousey,  M.  D., 
Consulting  Surgeon  to  St.  Bartholomew's  Hospital,  New  York.  Octavo 
of  I  ii6  pages,  with  750  practical  illustrations,  16  in  colors. 

Cloth,  $7.00  net  ;  Half  Morocco,  ^8.50  net. 

FOR  THE   PRACTITIONER 

This  new  work  by  such  an  eminent  authority  is  destined  to  take  a  leading 
place  among  books  on  this  subject.  Written  primarily  for  the  general  prac- 
titioner, it  gives  him  just  the  information  he  wishes  to  have  regarding  the  use  of 
medical  electricity,  the  therapeutic  results  obtained,  etc.  At  the  same  time  it 
tells  the  specialist  how  the  most  eminent  electrotherapeutists  are  securing  results, 
the  latest  authorities  in  every  country  having  been  consulted  for  details  of  prac- 
tical value.  The  work  gives  explicit  directions  for  the  care  and  regulation  of 
static  machines,  .r-ray  tubes,  and  all  apparatus.  The  author  tells  how  to  make 
x-ray  pictures  by  a  practical  technic  easily  followed.  Dental  radiography  the 
author  has  made  his  own. 

The  Military  Surgeon 

"  The  whole  subject  of  medical  and  surgical  electricity  is  covered  in  these  pages.  Not 
only  is  it  covered,  but  in  great  detail."  , 

McKenzie  on  Exercise  in 
Education   and    Medicine 

Exercise  in  Education  and  Medicine.  By  R.  Tait  McKenzie,  B.A.^ 
M.  D.,  Professor  of  Physical  Education  and  Director  of  the  Department, 
University  of  Pennsylvania.  Octavo  of  393  pages,  with  346  original 
illustrations.  Cloth,  $3.50  net. 

ILLUSTRATED 

This  work  is  a  full  and  detailed  treatise  on  the  application  of  systematized 
exercise  in  the  development  of  the  normal  body  and  in  the  correction  of  certain 
diseased  conditions  in  which  gymnastics  have  proved  of  value. 

D.  A.   Sargeant,   M.    D.,   Director  of  Hcmenway  Gymnasium,  Harvard  University. 

"  It  cannot  fail  to  be  helpful  to  practitioners  in  medicine.  The  classification  of  athletic 
games  and  exercises  in  tabular  form  for  different  ages,  sexes,  and  occupations  is  the  work  of  an 
expert.     It  should  be  in  the  hands  of  every  physical  educator  and  medical  practitioner." 


THE   PRACTICE    OF  MEDICINE 


Anders* 
Practice   of  Medicine 


A  Text=Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo,  1326  pages,  fully  illustrated.  Cloth,  $'^.^0  net;  Half 
Morocco,  $'j.oo  net. 

THE  NEW  (10th)  EDITION 

The  success  of  this  work  is  no  doubt  due  to  the  extensive  consideration  given 
to  Diagnosis  and  Treatment,  under  Dififerential  Diagnosis  the  points  of  distinction 
of  simulating  diseases  being  presented  in  tabular  form.  In  this  new  edition 
Dr.  Anders  has  included  all  the  most  important  advances  in  medicine,  keeping 
the  book  within  bounds  by  a  judicious  elimination  of  obsolete  matter.  A  great 
many  articles  have  also  been  rewritten. 

Wm.  E.  Quine,  M.  D.. 

Professor  of  Medicine  and  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
"  I  consider  Anders'  Practice  one  of  the  best  single-volume  works  before  the  profession  at 
this  time,  and  one  of  the  best  te.xt-books  for  medical  students." 


DaCosta's  Physical  Diagnosis 

Physical  Diagnosis.  By  John  C.  DaCosta,  Jr.,  M.  D.,  Associate 
in  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia.  Octavo 
of  557  pages,  with  225  original  illustrations.     Cloth,  33.50  net. 

NEW  (2d)   EDITION 

Dr.  DaCosta' s  work  is  a  thoroughly  new  and  original  one.  Every  method 
given  has  been  carefully  tested  and  proved  of  value  by  the  author  himself. 
Normal  physical  signs  are  explained  in  detail  in  order  to  aid  the  diagnostician  in 
determining  the  abnormal.  Both  direct  and  differential  diagnosis  are  emphasized. 
The  cardinal  methods  of  examination  are  supplemented  by  full  descriptions  of 
technic  and  the  clinical  utility  of  certain  instrumental  means  of  research. 
Dr.   Henry  L.  Eisner.   Professor  'f  Medicine  at  Syracuse  University. 

'•  I  have  reviewed  tliis  book,  and  am  thoroughly  convinced  that  it  is  one  of  the  best  ever 
written  on  this  subject.      In  every  way  I  find  it  a  superior  production." 


SAUNDERS'   BOOKS  ON 


Sahli*s  Diagnostic  Methods 


A  Treatise  on  Diagnostic  Methods  of  Examination.  By  Prof, 
Dr.  H.  Sahli,  of  Bern.  Edited,  with  additions,  by  Nath'l  Bowditch 
Potter,  M.  D.,  Assistant  Professor  of  Clinical  Medicine,  Columbia  Uni- 
versity (College  of  Physicians  and  Surgeons),  New  York.  Octavo  of 
1229  pages,  illustrated.     Cloth,  ;^6.50  net  ;  Half  Morocco,  $8.00  net. 

THE  NEW  (2d)  EDITION,  ENLARGED  AND  RESET 
Containing  all  the  Matter  of  the  New  Fifth  German  Edition — And  More 

The  American  edition  of  Dr.  Sahli' s  great  work  met  with  the  immediate  suc- 
cess accorded  the  original  German.  The  reason  for  this  success  is  obvious.  It 
is  a  practical  diagnosis,  written  and  edited  by  practical  clinicians.  So  thorough 
has  been  the  revision  for  this  edition  that  it  was  found  necessary  practically  to 
reset  the  entire  work.  Every  line  has  received  careful  scrutiny,  adding  new 
matter,  eliminating  the  old. 

Lewellys  F.  Barker,  M.  D. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  University 
"  I  am  delighted  with  it,  and  it  will  be  a  pleasure  to  recommend  it  to  our  students  in  the 
Johns  Hopkins  Medical  School." 


Friedenwald  and  Ruhrah 
on  Diet 


Diet  in  Health  and  Disease.  By  Julius  Friedenwald,  M.  D., 
Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah,  M.  D.,  Pro- 
fessor of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 
Baltimore.     Octavo  of  764  pages.     Cloth,  S4.00  net. 

THE  NEW  (3d)   EDITION 

This  new  edition  has  been  carefully  revised,  making  it  still  more  useful  than  the  two 
editions  previously  e.\hausted.  The  articles  on  milk  and  alcohol  have  been  rewritten,  additions 
made  to  those  on  tuberculosis,  the  salt-free  diet,  and  rectal  feeding,  and  several  tables  added, 
including  Winton's,  showing  the  composition  of  diabetic  foods. 

George  Dock.  M.  D. 

Professor  of  Theory  and  Practice  and  of  Clinical  Medicine,    Tulane    University. 
"  It  seems  to  me  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  available. 
I  am  especially  glad  to  see  the  long  list  of  analyses  of  different  kinds  of  foods." 


PRACTICE    OF  MEDICIXE 


Oertel  on  Bright's   Disease 

The  Anatomic   Histological    Processes  of    Bright's   Disease. — By 

HoRST  Oertel.  M.  D.,  Director  of  the  Russell  Sage  Institute  of 
Pathology,  New  York.  Octavo  of  227  pages,  with  44  illustrations  and 
6  colored  plates.     Cloth,  ^5.00  net;   Half  Morocco,  $6.50  net. 

ILLUSTRATED 

These  lectures  deal  with  the  anatomic  histological  processes  of  Bright' s 
diseai,e,  and  in  a  somewhat  different  way  from  the  usual  manner.  Everywhere 
relations  are  emphasized  and  an  endeavor  made  to  reconstruct  the  whole  as  a 
unit  of  interwoven  processes. 

The  Lancet,  London 

"Dr.  Oertel  gives  a  clear  and  intelligent  idea  of  nephritis  as  a  continuous  process.  We 
can  strongly  recommend  this  book  as  thoughtful,  scientific,  and  suggestive." 


Fenwick  on  Dyspepsia 

Dyspepsia — By  William  Soltau  Fexwick,  M.  D.,  of  London, 
England.     Octavo  volume  of  485  pages,  illustrated.     Cloth,  ;^3.oo  net. 

Dr.  Fenwick  takes  up  this  important  disease  in  a  thoroughly  systematic  way. 
He  discusses  the  causes,  pathology,  symptoms,  diagnosis,  prognosis,  and  treat- 
ment with  a  clearness,  a  detiniteness,  and,  withal,  a  conciseness  that  makes  his 
work  the  most  practical  and  useful  on  this  subject. 

Southern  Medical  Journal 

"The  suggestions  on  treatment  are  logical  and  practical,  being  particularly  helpful  in 
many  of  those  perplexing  types  so  often  encountered." 


Smith's  What   to  Eat  and  Why 

What  to  Eat  and  Why.     By  G.  Carroll  Smith,    M.D.,  Boston. 
l2mo  of  312  pages.     Cloth,  $2.50  net. 

FOR  THE  PRACTITIONER 

With  this  book  you  no  longer  need  send  your  patients  to  a  specialist  to  be 
dieted — you  will  be  able  to  prescribe  the  suitable,  diet  yourself  just  as  you  do 
other  forms  of  therapy.  Dr.  Smith  gives  "the  why"  of  each  statement  he 
makes.  It  is  this  knowing  why  which  gives  you  confidence  in  the  book,  which 
makes  you  feel  that  Dr.  Smith  kno7vs. 


Slade's  Physical  Examination  and  Diagnostic  Anatomy 

Physical  Examination  and  Diagnostic  Anatomy. — By  Charles  B.  Slade,  M.D., 
Chief  of  Clinic  in  General  Medicine,  University  and  Bellevue  Hospital  Medical  College. 
I2mo  of  146  pages,  illustrated.      Cloth,  ^1.25  net. 

"In  this  volume  is  contained  the  fundamental  methods  and  principles  of  physical  examination,  well 
illustrated,  largely  by  line  drawings.  The  book  is  to  be  strongly  recommended." — Boston  Medical  and 
Surgical  Journal. 


lo  SAUNDERS'  BOOKS  ON 

AMERICAN   EDITION 

NOTHNAGEL'S  PRACTICE 

UNUKR    THE    EDITORIAL    SUPERVISION   OK 

ALFRED   STENGEL.   M.D. 

Professor  of  Medicine  in  the  University  of  Pennsylvaci" 


Typhoid  and  Typhus  Fevers 

By  Dr.  H.  Curschmann,  of  Leipsic.  Edited,  with  additions,  by  William 
OsLER,  M.  D.,  F.  R.  C.  P.,  Regius  Professor  of  Medicine,  Oxford  University, 
Oxford,  England.     Octavo  of  646  pages,  illustrated. 

Smallpox  (including  Vaccination),  Varicella,  Cholera  Asiatica, 
Cholera  Nostras,  Erysipelas,  Erysipeloid,  Pertussis,  and 
Hay  Fever 

By  Dr.  H.  Immermann,  of  Basle  ;  Dr.  Th.  von  Jurgensen,  of  Tubingen  ; 
Dr.  C.  Liebermeister,  of  Tubingen ;  Dr.  H.  Lenhartz,  of  Hamburg  ; 
and  Dr.  G.  Sticker,  of  Giessen.  The  entire  volume  edited,  with  additions, 
by  Sir  J.  W.  Moore,  M.  D.,  F.  R.  C.  P.  I.,  Professor  of  Practice,  Royal  Col- 
lege of  Surgeons,  Ireland.      Octavo  of  682  pages,  illustrated. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

By  William  P.  Northrup,  M.  D.,  of  New  York,  and  Dr.  Th.  von  Jur- 
gensen, of  Tiibingen.  The  entire  volume  edited,  with  additions,  by  William 
P.  Northrup,  M.  D.,  Professor  of  Pediatrics,  University  and  Bellevue  Hos- 
pital Medical  College,  New  York.  Octavo  of  672  pages,  illustrated,  including 
24  full-page  plates,  3  in  colors. 

Diseases  of  the  Bronchi,  Diseases  of  the  Pleura,  and  Inflam- 
mations of  the  Lungs 

By  Dr.  F.  A.  Hoffmann,  of  Leipsic  ;  Dr.  O.  Rosenrach,  of  Berlin ;  and 
Dr.  F.  Aufrecht,  of  Magdeburg.  The  entire  volume  edited,  with  additions, 
by  John  H.  Musser,  M.  D.,  Professor  of  Clinical  Medicine,  University  of 
Pennsylvania.  Octavo  of  1029  pages,  illustrated,  including  7  full-page  colored 
lithographic  plates. 

Diseases  of  the  Pancreas,  Suprarenals,  and  Liver 

By  Dr.  L.  Oser,  of  Vienna  ;  Dr.  E.  Neusser,  of  Vienna  ;  and  Drs.  H. 
Quincke  and  G.  Hoppe-Seyler,  of  Kiel.  The  entire  volume  edited,  with 
additions,  by  Reginald  H.  Fritz,  A.  M.,  M.  D.,  Hersey  Professor  of  the 
Theory  and  Practice  of  Physic,  Harvard  University  ;  and  Frederick  A. 
Packard,  M.  D.,  Late  Physician  to  the  Pennsylvania  and  Children's  Hos- 
pitals, Philadelphia.      Octavo  of  918  pages,  illustrated. 

SOLD  SEPARATELY— PER  VOLUME  :   CLOTH,   $5.00   NET ;    HALF  MOROCCO,  $6.00  NET 


PRACTICE    OF  MEDICINE  II 

AMERICAN   EDITION 

NOTHNAGEL^S  PRACTICE 

Diseases  of  the  Stomach 

By  Dr.  F,  Riegel,  of  Giessen.  Edited,  with  additions,  by  Charles  G. 
Stockton,  M.  D.  ,  Professor  of  Medicine,  University  of  Buffalo.  Octavo  of 
835  pages,  with  29  text-cuts  and  6  full-page  plates. 

Diseases  of  the  Intestines  and  Peritoneum  Second  Edition 

By  Dr.  Hermann  Nothnagel,  of  Vienna.  Edited,  with  additions,  by 
H.  D.  Rolleston,  M.  D.,  F.  R.  C.  P.,  Physician  to  St.  George's  Hospital, 
London.     Octavo  of  1 100  pages,  illustrated. 

Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

By  Dr.  G.  Cornet,  of  Berlin.  Edited,  with  additions,  by  Walter  B. 
James,  M.  D.,  Professor  of  the  Practice  of  Medicine,  Columbia  University, 
New  York.      Octavo  of  806  pages. 

Diseases  of  the  Blood   {Anemia,  chlorosis.  Leukemia,  and  Pseudoleukeviia') 

By  Dr.  P.  Ehrlich,  of  Frankfort-on-the-Main  ;  Dr.  A.  Lazarus,  of  Char- 
lottenburg ;  Dr.  K.  von  Noorden,  of  Frankfort-on-the-Main  ;  and  Dr. 
Felix  Pinkus,  of  Berlin.  The  entire  volume  edited,  with  additions,  by  Alfred 
Stengel,  M.D.,  Professor  of  Medicine,  University  of  Pennsylvania.  Octavo 
of  714  pages,  with  text-cuts  and  13  full-page  plates,  5  in  colors. 

Malarial  Diseases,  Influenza,  and  Dengue 

By  Dr.  J.  Mannaberg,  of  Vienna,  and  Dr.  O.  Leichtenstern,  of  Cologne. 
The  entire  volume  edited,  with  additions,  by  Ronald  Ross,  F.  R.  C.  S.  (Eng.), 
F.  R.  S.,  Professor  of  Tropical  Medicine,  University  of  Liverpool  ;  J.  W.  W. 
Stephens,  M.  D.,  D.  P.  H.,  Walter  Myers  Lecturer  on  Tropical  Medicine, 
University  of  Liverpool  ;  and  Albert  S.  GrUnbaum,  F.  R.  C.  P.,  Professor 
of  Experimental  Medicine,  University  of  Liverpool.  Octavo  of  769  pages, 
illustrated. 

Diseases  of  Kidneys  and  Spleen,  and  Hemorrhagic  Diatheses 

l)y  Dr.  H.  Senator,  of  Berlin,  and  Dr.  M.  Litten,  of  Berlin.  The  entire 
volume  edited,  with  additions,  by  James  B.  Herrick,  M.  D.,  Professor  of  the 
Practice  of  Medicine,  Rush  Medical  College.     Octi^vo  of  815  pages,  illust. 

Diseases  of  the  Heart 

By  Prof.   Dr.  Th.  von  Jurgensen,  of  Tiibingen  ;  Prof.  Dr.  L.  Krehl, 

of  Greifswald  ;  and  Prof.    Dr.    L.  von  Schrotter,  of  Vienna.     Edited  by 

George  Dock,   M.D.,   Professor  of  Theory  and  Practice  of  Medicine  and 

Clinical  Medicine,  Tulane  LTniversity.      Octavo,  848  pages,  illustrated. 

SOLD  SEPARATELY— PER  VOLUME:    CLOTH,  $5.00  NET  ;    HALF  MOROCCO,  $6  00    NET 

Goepp's    State    Board    Questions 

NEW   (2d)  EDITION 
State  Board  Questions  and  Answers.     By  R.  Max  Goepp,  M.D., 
Professor  of  Clinical  Medicine,  Philadelphia  Pol)/clinic.     Octavo  of  715 
pages.  Cloth,  1^4.00  net ;   Half  Morocco,  ^5.50  net. 

Pennsylvania  Medical  Journal 

"  Nothing  has  been  printed  whieh  is  so  .admirably  adapted  as  a  guide  and  self-quiz  for  those 
intending  to  take  State  Board  Examinations." 


12 


SAUNDERS'    BOOKS   ON 


Stevens*  Therapeutics  New  (sth)  Edition 

A  Text-Book,  of  Modern  Materia  Medica  and  Therapeutics. 
By  A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer  on  Physical  Diagnosis  in 
the  University  of  Pennsylvania.     Octavo  of  675  pages.     Cloth,  $3.50  net. 

Dr.  Stevens'  Therapeutics  is  one  of  the  most  successful  works  on  the 
subject  ever  published.  In  this  new  edition  the  work  has  undergone  a 
very  thorough  revision,  and  now  represents  the  very  latest  advances. 

The  Medical  Record,  New  York 

"  Anion"  tlie  numerous  treatises  on  this  most  important  branch  of  medical  practice, 
this  by  Dr.  Stevens  has  ranked  with  the  best." 

Butler's  Materia  Medica  New  (6th)  Edition 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  and  Head 
of  the  Department  of  Therapeutics  and  Professor  of  Preventive  and 
Clinical  Medicine,  Chicago  College  of  Medicine  and  Surgery,  Medical 
Department  Valpariso  University.  Octavo  of  702  pages,  illustrated. 
Cloth,  $4.00  net;  Half  Morocco,  $5.50  net. 

For  this  sixth  edition  Dr.  Butler  has  entirely  remodeled  his  work,  a  great 
part  having  been  rewritten.  All  obsolete  matter  has  been  eliminated,  and 
special  attention  has  been  given  to  the  toxicologic  and  therapeutic  effects 
of  the  newer  compounds. 

Medical  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to  the 
completeness  of  the  text." 

Sollmann's  Pharmacology  New  (2d)  Edition 

A  Text-Book  of  Pharmacology.  By  Torald  Sollmann,  M.  D., 
Professor  of  Pharmacology  and  Materia  Medica,  Western  Reserve  Uni- 
versity.    Octavo  of  1070  pages,  illustrated.     Cloth,  $4.00  net. 

The  author  bases  the  study  of  therapeutics  on  systematic  knowledge  of 
the  nature  and  properties  of  drugs,  and  thus  brings  out  forcibly  the  mtimate 
relation  between  pharmacology  and  practical  medicine. 

J.  F.  Fotheringham,   M.  D.,    Trinity  Medical  College,    Toronto. 

"  The  work  certainly  occupies  ground  not  covered  in  so  concise,  useful,  and  scientific  a 
manner  by  any  other  text  I  have  read  on  the  subjects  embraced." 

Amy's  Pharmacy 

Principles  of  Pharmacy.  By  Henry  V.  Arny,  Pk.  G.,  Ph.  D., 
Columbia  University,  New  York.  Octavo  of  11 75  pages,  with  246  illtis- 
trations.     Cloth,  $5.00  net. 

George  Reimann,  Ph.  G.,  Secretary  of  the  New    York  State  Board  of  Pharmacy. 

"  I  would  say  that  the  book  is  certainly  a  great  help  to  the  student,  and  I  think  it  ought 
to  be  in  the  hands  of  every  person  who  is  contemplating  the  study  of  pharmacy." 


THERAPEUTICS  AND  MATERIA  MEDIC  A  13 


Hinsdale's   Hydrotherapy 

Hydrotherapy :  A  Treatise  on  Hydrotherapy  in  General ;  Its 
Application  to  Special  Affections  ;  the  Technic  or  Processes  Employed, 
and  a  Brief  Chapter  on  the  Use  of  Waters  Internally.  By  Guy  Hins- 
dale, M.  D.,  Fellow  Royal  Society  of  Medicine  of  Great  Britain. 
Octavo  of  466  pages,  illustrated.     Cloth,  ^3.50  net. 

INCLUDING  CROUNOTHERAPY 

The  treatment  of  disease  by  hydrotherapeutic  measures  has  assumed  such  an 
important  place  in  medical  practice  that  a  good,  practical  work  on  the  subject 
is  an  essential  in  every  practitioner's  armamentarium.  This  new  work  supplies 
all  needs.  It  describes  fully  the  various  kinds  of  baths,  douches,  sprays  ;  the 
application  of  heat  and  cold  ;  the  internal  use  of  mineral  waters  and  all  other 
procedures  included  under  hydrotherapeutic  measures. 

The  Medical  Record 

"  We  cannot  conceive  of  a  work  more  useful  to  the  general  practitioner  than  this,  nor  one 
to  which  he  would  resort  more  frequently  for  reference  and  guidance  in  his  daily  work." 


Kelly's  Cyclopedia  of  Ameri- 
can Medical  Biography 

Cyclopedia  of   American    Medical  Biography.     By    Howard    A. 

Kelly,  M.  D.,  Johns  Hopkins  University.     Two  octavos,  averaging  525 

pages  each,  with  portraits.     Per  set :  Cloth,  ^lO.OO  net ;  Half  Morocco, 

$13.00  net. 

IN  TWO  VOLUMES 

Dr.  Kelly,  in  these  two  handsome  volumes,  presents  concise,  yet  complete, 
biographies  of  those  men  and  women  who  have  contributed  noteworthily  to  the 
advancement  of  medicine  in  America.  Dr.  Kelly's  reputation  for  painstaking 
care  assures  accuracy  of  statement.  There  are  about  one  thousand  biographies 
included. 

Swan' s  Prescription-writing  and  Formulary 

Prescrh'Tion-writino  and  Formulary.  By  John  M.  Swan,  M.  D.,  formerly 
Director  Glen  Springs  Sanitarium,  Watkins,  N.  Y.  i6mo  of  1S5  pages.  Flexible 
leather,  $1.25  net. 

Stewart's  Pocket  Therapeutics  and  Dose-book        l^^^^ 

Pocket  Therapkutics  AND  Dose-Book.  By  Morse  Stewart,  Jr.,  ^LD.  32mo 
of  263  pages.     Cloth,  ^i.oo  net. 


1 4  SAUNDERS*    BOOKS   ON 

GET  A  •  THE  NEW 

THE  BEST  I\  111  6  n  C  Ci  11  STANDARD 

Illustrated    Dictionary 


New  (6th)  Edition,  Entirely  Reset 

The  American  Illustrated  Medical  Dictionary By  \V.  A.  New- 
man Borland,  M.  D.,  Editor  of  "The  American  Pocket  Medical  Dic- 
tionary." Large  octavo  of  986  pages,  bound  in  full  flexible  leather. 
Price,  $4.50  net;  with  thumb  index,  $5.00  net. 

KEY  TO  CAPITALIZATION  AND  PRONUNCIATION— ALL  THE  NEW  WORDS 

Howard  A.  }^ei\\y,\l.\),.  Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University. 

"Dr.  Dorland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 


Thornton's  Dose=Book.  ^^^  (^th)  Edition 

Dose- Book  and  Manual  of  Prescription-Writing.  ByE.  Q.  Thornton,  M.D., 
Assistant  Professor  of  Materia  Medica,  Jefierson  Medical  College,  Philadelphia.  Post- 
octavo,  410  pages,  illustrated.      Flexible  leather,  $2.00  net. 

"  I  will  be  able  to  make  considerable  use  of  that  part  of  its  contents  relating  to  the  correct 
terminology  as  used  in  prescription-writing,  and  it  will  afford  me  much  pleasure  to  recom- 
mend the  book  to  my  classes,  who  often  fail  to  find  this  information  in  their  other  text- 
books."— C.  H.  Miller,  'i^l.H.,  Professor  of  Pharmacology,  Northwestern  Unizersity  Afedi- 
cal  School. 

Lusk  on  Nutrition  New  i^2dj  Edition 

Elements  of  the  .'Science  of  Nutrition.  By  Graham  Lusk,  Ph.  D.,  Professor 
of  Physiology  in  Cornell  University  Medical  School,  Octavo  of  402  pages.  Cloth, 
^3.00  net. 

"  I  shall  recommend  it  highly.  It  is  a  comfort  to  have  such  a  discussion  of  the  subject." 
— Lfwellys  F.  Barker,  M.  D.,  Johns  Hopkins  University. 

Camac's  "Epoch-making  Contributions" 

Epoch-making  Contributions  in  Medicine  and  Surgery.  Collected  and 
arranged  by  C.  N.  B.  Camac,  M.  D.,  of  New  York  City.  Octavo  of  450  pages,  illus- 
trated.    Artistically  bound,  $4.00  net. 

"  Dr.  Camac  has  provided  us  with  a  most  interesting  aggregation  of  classical  essays^ 
We  hope  that  members  of  the  profession  will  show  their  appreciation  of  his  endeavors." — 
Therapeutic  Gazette. 


PRACTICE,    MATERIA   MEDIC  A,   Etc.  15 

The  American  Pocket  Medical  Dictionary  New  (7th)  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  Newman  Dor- 
land,  M.  D.,  Editor  "  American  Illustrated  Medical  Dictionary."  610  pages.  Flexible 
leather,  with  gold  edges,  ^i.oo  net;   with  thumb  index,  ;^  1.25  net. 

Pusey  and  Caldwell  on  X-Rays  Second  Edition 

The  Practical  Application  of  the  Rontgen  Rays  in  Therapeutics  and 
Diagnosis.  By  William  Allen  Pusey,  A.  M.,  M.  D.,  Professor  of  Dermatology  in 
the  University  of  Illinois  ;  and  Eugene  VV,  Caldwell,  B.  S.,  Director  of  the  Edward 
N.  Gibbs  X-Ray  Memorial  Laboratory  of  the  University  and  Bellevue  Hospital  Medical 
College,  New  York.  Octavo  of  625  pnges,  with  200  illustrations.  Cloth,  ^5.00  net ; 
Half  Morocco,  I6.50  net. 

Cohen    and    Bshner's    Diag^nosis.      Second  Revised  Edition 

Essentials  of  Diagnosis.  By  S.  Solis-Cohen,  M.  D.,  Senior  Assistant  Professor 
in  Clinical  Medicine,  Jefferson  Medical  College,  Phila.  ;  and  A.  A.  Eshner,  M.  D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Post-octavo,  382  pages  ;  55 
illustrations.      Cloth,  ^i.oo  net.     In  Saunders'  Question- Co>iif>end  Series. 

Morris*  Materia  Medica  and  Therapeutics.  New  (7th)  Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription-Wkiting. 
By  Henry  Morris,  M.  D.,  late  Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Phila.  Revised  by  W.  A.  Bastedo,  M.  D.,  Instructor  in  Materia  Medica  and 
Pharmacology  at  Cokimbia  University.  1 2mo,  300  pages.  Cloth,  ^1,00  net.  In  Saunders^ 
Question-  Coiiipend  Series. 

Williams*  Practice  of  Medicine 

Essentials  of  the  Practice  of  Medicine.  By  W.  R.  Williams,  M.D., 
formerly  Instructor  in  Medicine  and  Lecturer  on  Hygiene,  Cornell  University  ;  and 
Tutor  in  Therapeutics,  Columbia  University,  N.  Y.  l2mo  of  456  pages,  illustrated. 
In  Saunders'   Question- Cow/>end  Series.     Double  numl>er,  $1.75  net. 

Todd's  Clinical  Diagnosis  ^^^  ^^^  ^^d)  Edition 

A  Manual  of  Clinical  Diagnosis.  By  James  Campbell  Todd,  M.  D.,  Professor 
of  Pathology,  University  of  Colorado.  l2mo  of  469 pages,  with  164  text-illustrations 
and  10  colored  plates.     Cloth,  $2.25  net. 

Bridge  on  Tuberculosis 

Tuberculosis.  By  Norman  Bridge,  A.  M.,  M.  D.,  Emeritus  Professor  of  Medicine 
in  Rush  Medical  College.     i2mo  of  302  pages,  illustrated.     Cloth,  #1.50  net. 

Boston's  Clinical  Diagnosis  Second  Edition 

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Arnold's  Medical  Diet  Charts 

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Mathews*  How  to  Succceed  in  Practice 

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Jakob  and  Eshner's  Internal  Medicine  and  Diagnosis 

Atlas  and  Eitkjmk  of  Imeknal  Mi-.dicine  and  Clinical  Diagnosis.  Bv  Dr. 
Chk.  Jakoh,  of  Erlangen.  Edited,  with  additions,  by  A.  A.  Eshner,  M.  D.',  Pro- 
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Lockwood's  Practice  of  Medicine.  „  Second  Edition. 

Revised  and  Enlarged 

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Attending  Physician  to  the  Bellevue  Hospital,  New  York  City.  Octavo,  847  pages* 
with  79  illustrations  in  the  te.\t  and  22  full-page  plates.      Cloth,' 34.00  net. 

Barton  and  Wells'  Medical  Thesaurus 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  W.  M.  Barton,  M.  D.,  and 
W.  A.  Wells,  M.  D.,  of  Georgetown  University,  Washington,  D.  C.  i2mo  of  535 
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Stevens'  Practice   of  Medicine  New  ^Pth)  Edition 

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Professor   of    Pathology,    Woman's    Medical    College,    Phila.  Specially   intended   for 

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Saunders*  Pocket  Formulary  New  (9th)  Edition 

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taining Posologic  Table,  Formulas  and  Doses  for  Hypodermic  Medication,  Poisons  and 
their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Petal  Head,  Obstetrical  Table, 
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Gould  and  Pyle's  Curiosities  of  Medicine 

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Hatcher  and  Sollmann*s  Materia  Medica 

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Eichhorst's  Practice  of  Medicine 

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